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ADENOMYOMA 


OF   THE 


UTERUS 


i^ 


THOMAS    STEPHEN   CULLEN 

ASSOCIATE      PROFESSOR      OF      GYNECOLOGY      IN     THE      IOHNS     HOPKINS     UNIVERSITY 

ASSOCIATE      IN      GYNECOLOGY      IN      THE       IOHNS      HOPKINS      HOSPITAL 


ILLUSTRATED 

BY 
HERMANN    BECKER    and    AUGUSf    HORN 


rilll  API  1  I'lll A      \M>     LONDON 

W.    B.   SAUNDERS    COMPANY 

i  wo8 


Copyright,  1908,  by  W.  B.  Saunders  Company 


PRINTED     IN      AMERICA 


TO  THE  MEMORY  OF 
MY   FATHER 

XBi)t  Urtorrcnu  gliomas  Cullrn 

WHO  WAS  BORN  IN  THE  COUNTY  OF  FERMANAGH,  IRELAND. 
IN  1S36.  AND  DIED  IN  LONDON,  CANADA,  IN  1895, 

THIS  BOOK 

IS  AFFECTIONATELY  DEDICATED 


PREFACE 


One  afternoon  in  October,  1N94,  while  making  the  routine 
examination  of  the  material  from  the  operating  room  I  found  a 
uniformly  enlarged  uterus  about  four  times  the  natural  size.  On 
opening  it  I  found  that  the  increase  in  size  was  due  to  a  diffuse 
thickening  of  the  anterior  wall.  Professor  William  II.  Welch, 
when  consulted,  said  that  the  condition  was  evidently  a  most  un- 
usual one  and  surest ed  that  sections  be  made  from  the  entire 
thickness  of  the  uterine  wall.  Examination  of  these  sections  showed 
that  the  increase  in  thickness  was  due  to  the  presence  of  a  diffuse 
myomatous  tumor  occupying  the  inner  portion  of  the  uterine  wall, 
and  that  the  uterine  mucosa  was  at  many  points  flowing  into  the 
diffuse  myomatous  tissue.  A  few  months  later  a  second  adeno- 
myoma  was  met  with.  Both  of  these  cases  were  reported  at  the 
Johns  Hopkins  Hospital  Medical  Society  in  March,  1S95,  and  pub- 
lished in  the  Johns  Hopkins  Hospital  Reports,  Vol.  6,  1896. 

Since  that  time  we  have  carefully  inspected  all  our  material 
for  adenomyoma  and  have  encountered  over  ninety  adenomyomata 
of  various  kinds  in  the  uterus. 

v  Our  material  has  been  obtained  chiefly  from  the  Gynecolog- 
ical Department  of  the  Johns  Hopkins  Hospital,  from  Dr.  Kelly's 
private  sanatarium  and  from  my  cases  at  the  Church  Home  and 
Infirmary  and  elsewhere.  The  exact  source1  in  each  case  is  given 
in  tin1  tables  of  cases  at  the  end  of  the  book,  from  which  also  the 
reader  can  find  at  a  glance  the  page  number  o^i  any  gynecological 
or  pathological  number  mentioned  in  the  book. 

After  the  publication  of  von  Recklinghausen's  work  on  A.deno- 
myoma   in    1896  considerable    controversy   arose    :is    to    the  origin 


VI  PREFACE 

of  the  gland  elements  in  adenomyomata.  Our  first  cases  had 
clearly  shown  that  the  glands  in  the  diffuse  myoma  owed  their 
origin  to  a  flowing  outward  of  the  normal  uterine  mucosa.  In 
all  subsequent  cases  these  tumors  were  examined  most  carefully 
from  this  standpoint.  Sometimes  the  mucous  membrane  origin 
was  easily  proved,  but  in  many  cases  not  only  were  numerous 
sections  necessary,  but  in  some  instances  a  clear  idea  of  the  con- 
dition was  obtainable  only  after  an  examination  of  very  large  sec- 
tions embracing  the  entire  uterine  wall.  This  labor  yielded  fruit, 
as  in  nearly  every  case  in  which  diffuse  adenomyoma  existed  we 
have  been  able  to  trace  the  mucous  membrane  origin  of  the  glands. 
Much  credit  for  the  large  and  beautiful  sections  is  due  to  our  labora- 
tory assistant,  Mr.  Benjamin  O.  McCleary. 

While  endeavoring  to  ascertain  the  method  of  development 
of  adenomyomata  I  have  likewise  been  trying  to  determine  how 
these  growths  can  be  recognized  clinically.  I  cannot  help  feeling 
that  any  one  who  reads  the  chapter  on  symptoms  will  agree  with 
us  that  diffuse  adenomyoma  has  a  fairly  definite  clinical  history 
of  its  own  and  that  in  the  majority  of  cases  it  can  be  diagnosed 
with  a  relative  degree  of  certainty.  This  definite  gain  in  our  know- 
ledge certainly  emphasizes  the  fact  that  any  morbid  process  should 
be  studied  carefully  both  from  its  histological  and  also  from  its 
clinical  aspects  and  shows  the  importance,  for  all  those  who  do 
surgical  work,  of  a  thorough  familiarity  with  the  histological  appear- 
ances of  the  pathological  processes  they  are  dealing  with. 

In  this  book  the  publishers  have  deemed  it  wise  to  use  a  larger 
type  than  usual.  At  the  beginning  of  each  case  an  epitome  is 
given  and  in  the  succeeding  paragraphs  the  essential  features  are 
emphasized  by  the  employment  of  spaced  type.  This  arrangement 
will  permit  those  who  wish  to  obtain  the  gist  of  the  book  to  do 
so  in  a  few  hours,  without  going  into  all  the  minor  details,  provided 
that  their  reading  is  supplemented  by  a  careful  study  of  the  illus- 
trations. 

I  wish  to  express  my  thanks  to  Dr.  Henry  M.  Hurd  for  his  ad- 
vice on  numerous  occasions,  to  my  brother,  Dr.  Ernest  K.  Cullen, 


PREFA(  l.  Vll 

for  the  manifold  details  lie  has  looked  after  for  me,  and  to  Miss 
('or;,  Reik,  my  secretary,  for  the  continued  interesl  she  has  taken 
in  the  preparal ion  of  this  volume. 

I  am  under  especial  obligation  to  Dr.  Frank  R.  Smith  for  his 
revision   of   the   manuscript,  and    for  correcting   the   proof-sheets. 

To  my  friends  Mr.  Hermann  Becker  and  Mr.  August  Horn  I 
am  deeply  indebted  for  their  excellenl  and  faithful  illusl  ral  ions. 

With  the  publishers.  \Y.  B.  Saunders  Company,  my  relations 
have  been  most  cordial  and  I  am  especially  mindful  of  the  many 
kindnesses  shown  by  Mr.  R.  W.  Greene,  one  of  the  vice-presidents 
of  the  company. 

Thomas  S.  Cullen. 

Baltimore,  May  1.   L908 


CONTENTS 


(  'll  VPTER     I  pAGK 

Adenomyoma  of  the  Uterus 1 

(  'll  VPTER    I  I 

Cases  of  Adenomyoma  in  which  the  Uterus  R  et  vins  a  Rel  \ ti\  ely  Normal 

(  lONTOUR I".  I 

Chapter  III 
Cases  of  Adenomyoma  i\  which  the  Uterus  Retains  a  Relatively  Normal 

(  !l  (NTOUR 52 

Chapter   IV 
Cases  of  Adenomyoma  i\  which  the  Uterus  Retains  a  Relatively  Normal 
Contour ^ 

Chapter  V 
Subperitoneal  vnd  [ntralig  what vry  Adenomyomata 125 

Chapter  VI 
Si  bmucous  Adenomyom  \ta 156 

Chapter  VII 
Cervical  Adenomyomata L65 

Chapter  VI 1 1 
Condition  of  the  Tubes  and  Ovaries  \\hi:\  Adenomyoma  of  the  Uteri  - 
Exists 171 

cr  vpter    i  x 
The  Clinical  Picture  inC  vses  <>f  Adenomyoma  of  the  Uterus  17^ 

(  'll  VPTER     X 

Differential  Diagnosis  in  C  vses  of  Adenomyoma  of  the  Uterus  177 

( 'll  VPTER    X  I 

Treatment  of  Adenomyomata  of  the  Uteri  -  186 

Ch  VPTER    XI  I 

Prognosis  in  Cases  of  Adenomyoma  of  the  Uterus  L87 


X  CONTEXTS 

Chapter  XIII  pAGE 

Origix  of  Adenomyomata  of  the  Uterus 193 

Chapter  XIV 
Causes  of  Adenomyoma  of  the  Uterus 199 

Chapter  XV 
Hypertrophy  of  the  Cervix  axd  Diffuse  Adenomyoma  of  the  Body  of  the 

Uterus 200 

Chapter  XVI 
Adenomyoma  in  oxe  Horx  of  a  Bicorxate  Uterus 203 

Chapter  XVII 
Diffuse  Adenomyoma  of  the  Body  of  the  Uterus  Occurrixg  in  Cases  of 

Squamous-cell  Carcinoma  of  the  Cervix : 206 

Chapter  XVIII 
Adexocarctxoma  axd  Adexomyoma  Occurrixg  Ixdepexdextly  ix  the  Body 

of  the  Same  Uterus 218 

Chapter  XIX 
Adexocarctxoma  of  the  Body  of  the  Uterus  Developixg  from  ax  Adeno- 
myoma    222 

Chapter  XX 
A  .Multiplicity  of  Pathological  Chaxges  ix  the  Pelvis 228 

Chapter  XXI 
Diffuse  Myomatous  Thickexixg  of  the  Uterus  but  xo  Glaxdular  Inva- 
sion    230 

Chapter  XXII 
Adenomyoma  of  the  Uterixe  Horx 235 

Chapter  XXIII 
Pregxaxcy  ix  the  Left  Fallopiax  Tube;     Discrete  Uterixe  Myomata; 
Diffuse  Adexomyoma  ix  the  Right  Uterixe  Horx  with  the  Develop- 
mext  of  Decidual  Cells  arouxd  the  Glaxds  ix  the  Adexomyoma 246 

Chapter  XXIV 
Adexomyoma  of  the  Rouxd  Ligamext 250 

Summary.  ..'. 260 

Ixdex  of  Cases  Arraxged  According  to  their  Gynecological  Xumbers.  .  .   263 

Index  of  Gyxecological-Pathological  Numbers 265 

Ixdex 267 


LIST  OF  ILLUSTRATIONS 


I  1...  PAGE 

1.  Diffuse  Ad enomyoma  of  the  Posterior  Wall  of  the  Uterus  lo 

2.  1  Diffuse  Adenomyom  \  of  the  l'<  isterior  Uterine  Wali 12 

3.  Diffuse  Aden*  >my<  m  \  i  >f  the  P<  isterk  ih  Uterine  W  \i.i L9 

I.  Diffuse  Adenomyomatous  Thickening  i\  the  Fundus  \\i>  Posterior 

Uterine  Wall  with  Extension  <  n  muss,   of  the  Mucosa  into  a 

Lar(;k  Cki.\  m;  between  Myomatous  Masses 26 

5.  Diffuse  Adenomyoma  Forming  a  Complete  Zone  around  the  Uterine 

('  W  ITY 35 

6.  Diffuse  Adenomyoma  of  the  Uterine  Wall  with  Marked  Extension 

of  the  Mucosa  into  the  Growth 37 

7.  Extension  of  the  Mucosa  into  a  Diffuse  .Myoma  of  the  Uteres 38 

8.  Diffuse  Adenomyoma  of  the  Anterior  Uterine  Wali 42 

9.  Diffuse  Adenomyoma  of  the  Anterior  Uterine  W  w.i 43 

K).  Mode  of  Extension  of  Uterine  (  Ilands  into  a  Diffuse  Adenomyoma  ....  44 

1 1.  Diffuse  Adenomyoma  of  the  Uterus  with  Sever  \i.  I  Discrete  Myomata  .  .  48 

12.  Diffuse  Adenomyoma  of  the  Posterior  Uterine  Wali 49 

13.  Diffuse  Adenomyoma  of  the  Uteris   Involving  the  Anterior   and 

I  'i  isterior  Walls  and  Fundus 55 

14.  Diffuse  Adenomyoma  of  the  Anterior  and  Posterior  Uterine  Walls  .  56 

15.  Method  of  Penetration  of  the  Mucosa  in  a  Diffuse  Adenomyoma  of 

the  Uterine  Wall 57 

lti.  Extension  of  Uterine  Glands  into  the  Diffuse  Myomatous  Tissue  «>f 

an  Adenomyoma 59 

17.  Interstitial    and    Subperitoneal    Uterine    Myomata.     Interstitial 

Adenomyoma 65 

18.  Small  Adenomyoma  of  the  Fundus  of  the  Uterus 66 

10.  Diffuse  Adenomyoma  of  the  Uterus ('»'.' 

20.  Diffuse  Adenomyoma  of  the  Uterine  Wall 70 

21.  Cyst-like  Spaces  Just  Beneath  the  Peritoneum  in  Diffuse  Adeno- 

myoma of  the  Uterus 72 

22.  The  Mucos  \  Lining  One  of  the  Cyst-like  Sp  v.ces  Situated  Just  Beneath 

the  Peritoneum  in  a  Diffuse  Adenomyom  \  of  the  Uterus 7  1 

23.  Diffuse  Adenomyoma  of  the  Anterior  Uterine  Wali 77 

24.  Diffuse  Adenomyoma  of  the  Anterior  Uterine  W\li 7^ 

25.  Cross-section  of  \  (  }land  Taken  fr<  m  Fig.  2 1  vr  d 80 

26.  A  Branching  Gland  from  a  Glandular  Area  in  \\  Adenomyom  \ 81 

27.  Dd?fuse  Adenomyoma  of  the  Body  of  the  Uterus 90 

28.  Extension  of  the  Mucosa  ento  the  Muscle  in  vCaseof  Diffuse  Adeno- 

myom \  of  the  Uterus 91 


Xll  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

29.  Method  of  Penetration  of  a  Single  Uterine  Gland  into  the  Diffuse 

Myomatous  Growth  of  an  Adenomyoma 92 

30.  Diffuse  Adenomyoma  of  the  Body  of  the  Uterus 96 

31.  Discrete  Uterine  Myomata.     Diffuse  Adenomyoma  with  the  Glands 

Originating  from  the  Mucosa.     Adenomyoma  of  the  Left  Uter- 
ine Horn 101 

32.  Longitudinal  Section  of  Discrete  Myomata;    Discrete  Adenomyoma 

Near  the  Left  Ltterine  Horn 102 

33.  Subperitoneal,  Interstitial  and  Submucous  Uterine  Myomata;     Dif- 

fuse Adenomyoma  of  the  Entire  Fundus 107 

34.  Discrete  Myoma  of  the  Cervix;   Diffuse  Adenomyoma  of  the  Body  of 

the  Uterus HI 

35.  Diffuse  Adenomyoma.  of  the  Body  of  the  Uterus 116 

36.  Diffuse  Adenomyoma  of  the  Fundus  with  Cystic  Spaces  in  the  Left 

Uterine  Horn 120 

37.  A  Cystic  Subperitoneal  Adenomyoma  of  the  Uterus 130 

38.  A  Cystic  Subperitoneal  Adenomyoma  of  the  Uterus 131 

39.  A  Subperitoneal  Cystic  Adenomyoma  Occurring  in  the  Case  of  a  Large 

Myomatous  Uterus 134 

40.  Cystic  Subperitoneal  Adenomyoma  of  the  Uterus 136 

41.  Subperitoneal  and  Interstitial  Uterine  Myomata.     Adenomyoma  of 

the  Body  of  the  Uterus.     Adenomyoma  Springing  from  the  Left 
Utero-oyarian  Ligament 142 

42.  Cross-section  Through  a  Pedunculated  Subperitoneal  Adenomyoma  . .    1 44 

43.  An  Intraligamentary  and  also  Partly  Submucous  Cystic  Adenomyoma 

of  the  Uterus 151 

44.  A  Cystic  Intraligamentary  and  Partly  Submucous  Adenomyoma  of 

the  Uterus 152 

45.  The  Submucous  Portion  of  a  Cystic  Adenomyoma  of  the  Uterus 154 

46.  Submucous  Adenomyoma  of  the  Uterus 159 

47.  Submucous  Adenomyoma  of  the  Uterus,  the  Myomatous  Muscle  Being 

Riddled  with  Miniature  Uterine  Cavities 162 

48.  Interstitial  Uterine  Myomata  with  a  Small  Diffuse  Adenomyoma  in 

the  Cervix 168 

49.  Adenomyoma  in  the  Outer  Portion  of  the  Cervix  Near  the  Broad 

Ligament  Attachment 169 

50.  A  Cystic  Myoma  Macroscopically  Simulating  a  Cystic  Adenomyoma  ....  176 

51 .  A  Small  Uterine  Polyp 178 

52.  Large  Venous  Sinuses  in  the  Uterine  Mucosa  Causing  Severe  Hem- 

orrhages     179 

53.  Thickening  of  the  Uterine  Mucosa.     Marked  Dilatation  of  Some  of 

the  Glands  without  any  Atrophy   of  their  Epithelium;     very 
Dense  Stroma 181 

54.  A  Portion  of  a  Diffuse  Adenomyoma  of  the  Posterior  Wall  of  the 

Uterus 188 

55.  Diffuse  Adenomyoma 189 


LIST    OF    ILLUSTRATIONS  .Mil 

56.  Very  Extensive  Hypertrophy  of  the  Cervix.     Discrete  Myoma  and 

DlFFl  SE  ADENOMYOMA  01   THE   BODI    OF   THE  UTERI  8 .    200 

57.  ADENOMYOMA   l\  ONE  HORN  OF    \    BlCORN  \'l  l.    UTERUS 204 

58.  DlFFl  BE  ADENOMYOMA   l\  THE   BODI    I  IF  THE  I ITERUS '_'l»7 

59.  Squamous-cell  Carcinoma  of  the  Cervix;     Discrete  Subperitoneal 

wo   Interstitial  Myomata;    Diffuse  Adenomyoma  of  the  Pos- 
terior Uterine  Wali 209 

60.  Commencing  Diffi  be  Adenomyoma  of  the  Bodi  of  the  Uteri  s  Abso- 

Cl  \l  'ED  Willi  Al)\  ANCED  SQUAMOUS-CELL  CARCINOMA  OF  THE  CERVIX  _'  1  5 

61.  Adenocarcinoma  of  the  Body  of  the  Uterus  Associated  with  a  Small 

Subperit<  ineal  Adenomyoma 219 

()■_'.  Adenocarcinoma    Developing   from   a   Dilated   Gland   in   an   Adeno- 

my< ima  oh'  the  Uterus _''_'  l 

63.  .Myoma,  Aden* imyoma  and  Primary  Adenocarcinoma  ok  the  Body  ok  the 

Uterus;  Pyosalpinx  and  Primary  Adenocarcinom  \  ok  the  Ovary.  .   228 

(I  I.  Adenomyoma  of  the  Uterine  Horn 237 

65.  Adenomyomata  ok  Both  Uterine  Horns;   Discrete  Myomata;   Diffi  se 

Adenomyoma  ok  the  Uterus _'  l.'i 

(id.  Left  Tubal  Pregnancy;     Discrete  Uterine  .Myomata;    Adenomyoma 

ok  the  Right  Uterine  Horn  with   Decidual  Formation  in  the 

Stroma  Surrounding  the  Glands 247 

67.  Adenomyoma  ok  the  Round  Ligament 256 

68.  Adenomyoma  of  the  Round  Ligament _'.">7 


ADENOMYOMA  OF  THE  UTERUS 

CHAPTER   I 

ADENOMYOMA  OF  THE  UTERUS 

In  190.'].  in  a  review  of  the  literature  published  in  a  supplemenl 
to  Orth's  Festschrift,  I  reported  22  cases  of  adenomyoma  examined 
by  me  up  to  that  date.1  Since  then  I  have  paid  especial  attention 
to  these  growths  and  have  been  astonished  at  the  striking  frequency 
with  which  they  occur.  Out  of  a  total  of  1283  cases  of  myoma 
examined  from  April  1,  1893,  until  July  1,  1906,  73a  that  is.  about 
5.7  per  cent. — were  instances  of  adenomyoma."  I  have  included 
only  interstitial,  subperitoneal  and  submucous  adenomyomata  and 
large  adenomyomata  of  the  uterine  horns.  The  smaller  nodules 
so  frequently  present  in  the  cornua  have  been  purposely  omitted. 

Glandular  elements  have  from  time  to  time  been  noted  in  myo- 
mata,  and  according  to  Breus,'  Schroeder,  Ilerr  and  Grosskopf  had 
been  able  to  collect  a  total  of  one  hundred  cases  up  to  1884.  But 
not   until  the  appearance  of  the  masterly  work  of  von   Reckling- 

1  Cnllen,  Thomas  S.:  Adeno-Myoma  des  Uterus,  Verlag  von  Augusl  Birsch- 
wald.  Berlin,  1003. 

2  The  following  adenomyoma  cases  have  been  operated  upon  between  July  1st, 
L906,  and  Dec.31st,  1907:  Path.Nos.  10,109,  10,499,  10,560,  10,596,  10,617,  L0,669, 
10,677 (Gyn.  13,423),  10.707.  L0,844(Gyn.  13,590),  10,972,  Ll,078(Gyn.  13,679),  11,120, 
11,140.11.101,  11.10."),  11,849, 11,859,  1 1,863,  12,007,  making  a  total  of  19  cases;  showing 
beyond  peradventure  thai  this  disease  is  particularly  prevalent.     We  have  had  in 

all  92  cases  of  at lenomyoma. 

3  In  some  of  the  cases  no  microscopic  examination  was  made.     1"  positively 
exclude  the  presence  of  adenomyoma  it  would  have  been  necessary  t<>  take  sections 
from  many  parts  of  i  he  uterine  wall.      This  would  have  entailed  an  enormouf 
penditure  of  labor  that   was  often  impossible.     It  will  thus  he  seen  that  a  certain 
number  ^(  cases  o(  adenomyoma  have  probably  been  overlooked. 

*  Breus,  Carl:  Qeber  wahre  epithelfiihrende  Cystenbildung  in  Uterus-Myomen. 
Leipzig  und  Wien,  is*)  1. 

i 


2  ADENOMYOMA    OF    THE    UTERUS. 

hausen,1  published  in  1896,  had  this  subject  received  much  atten- 
tion.2 These  growths,  as  their  name  implies,  consist  of  gland  ele- 
ments and  myomatous  tissue.  They  form  a  distinct  class  of  their 
own,  and  on  microscopic  examination  their  recognition  is  eas}r. 
Even  in  the  gross  specimens  it  is  often  possible  to  render  a  positive 
diagnosis. 

For  the  use  of  clinicians  we  divided  these  growths  into  three 
classes,  although  it  will  be  readily  seen  that  one  class  may  merge 
imperceptibly  into  the  other.     The  divisions  are : 

(1)  Adenomyomata,  the  uterus  preserving  a  relatively3  normal 
contour. 

(2)  Subperitoneal  or  intraligamentary  adenonryomata. 

(3)  Submucous  adenomyomata. 

ADENOMYOMA  IN   WHICH   THE   UTERUS   PRESERVES  A  RELATIVELY  NORMAL 

CONTOUR 

The  uterus  may  be  nearly  normal  in  size,  as  in  Fig.  5  (p.  35), 
or  it  may  be  two  or  three  times  the  natural  size,  as  noted  in  Fig.  13 
(p.  55)  and  in  Fig.  23  (p.  77).  When  the  organ  is  considerably  en- 
larged, it  is  frequently  partly  covered  with  adhesions.  In  these 
uteri  there  is  a  myomatous  transformation  of  the  muscle;  the 
thickening  extends  from  the  mucosa  outward,  sometimes  involving 
the  wall  in  half  its  thickness,  or  at  other  times  reaching  even  as  far 
as  the  peritoneum  (Fig.  13,  p.  55).  Sometimes  it  is  limited  to  the 
anterior  or  posterior  wall  (Fig.  1,  p.  10,  and  Fig.  23,  p.  77),  but  may 

1  ATon  Recklinghausen,  Frieclrich:  Die  Adenomyome  unci  Cystadenome  der 
Uterus  und  Tubenwandung,  ihre  Abkunft  von  Resten  des  Wolff'schen  Korpers. 
Berlin,  1896.  (I  wish  to  express  my  deep  sense  of  obligation  to  Professor  v.  Reck- 
linghausen for  his  kindness  in  examining  sections  from  several  of  the  cases  and  for 
his  valuable  criticism  of  the  same.) 

2  Probably  the  best  article  written  in  this  country  on  adenomyoma  of  the  uterus 
was  that  by  Dr.  J.  M.  Baldy  and  Dr.  W.  T.  Longcope,  presented  to  the  Philadelphia 
Obstetrical  Society  and  published  in  the  American  Journal  of  Obstetrics,  1902, 
vol.  xlv,  p.  788. 

3 1  use  the  word  "relatively"  because  if  operative  interference  be  long  delayed 
some  of  the  discrete  myomata  so  frequently  found  may  assume  large  proportions  and 
almost  completely  overshadow  the  adenomyoma,  while  at  the  same  time  greatly 
altering  the  contour  of  the  uterus. 


DIFFUSE    .\l)i;\o.M  Vo.MA    OF   Till.    CJTERUS  3 

involve  both  (Fig.  ">,  p.  35).  Where  such  is  the  case,  we  have  a 
uterine  cavity  lined  with  a  mucosa  which  is  surrounded  by  a  thick 
zone  of  myomatous  muscle  and  covered  externally  with  a  mantle  of 
normal  muscle  of  variable  thickness.  The  myomatous  thickening 
is  diffuse  in  character,  consists  of  bundles  of  fibres  running  in  all 
directions  and  along  the  advancing  margin  gradually  merging  into 
the  normal  muscle,  in  contradistinction  to  the  condition  found  in 
simple  myomata,  which  are  sharply  circumscribed,  (liven  such 
thickenings  of  the  uterine  wall,  we  may  always  suspect  the  presence 
of  "land  elements. 

On  examining  the  uterine  cavity  it  is  usually  found  thai  the 
mucosa  at  one  or  more  points  extends  into  the  diffuse  myomatous 
tissue  beneath  (Fig.  1,  p.  10).  This  point  is  more  readily  verified 
by  examining  with  a  loup,  when  a  careful  scrutiny  of  the  diffuse 
myomatous  growth  will  discover  small,  round,  irregular,  triangular 
or  oblong  areas,  composed  of  a  waxy,  fairly  homogeneous  tissue, 
lying  between  myomatous  bundles.  These  areas  correspond  closely 
in  appearance  with  the  uterine  mucosa,  and  with  the  glass  one  can 
make  out  punctiform  openings,  which  are  cross-sections  of  glands. 
Frequently  such  areas  contain  cyst-like  spaces  varying  from  .5 
to  5  mm.  or  more  in  diameter  (Fig.  5,  p.  35,  Fig.  19,  p.  69).  Other 
and  larger  cyst-like  spaces  are  occasionally  found.  These  have 
smooth  inner  surfaces  and  a  lining  of  mucosa  often  1  mm.  in  thick- 
ness. They  are  in  reality  miniature  uterine  cavities.  Main-  of 
these  cyst-like  spaces  contain  fresh  blood  or  yellowish  blood  pigment, 
the  remains  of  old  hemorrhages.  The  small  cyst  spaces  may  readily 
be  mistaken  for  blood-vessels,  but  the  larger  ones  are  easily  rcc..-- 
nized.  Among  the  most  instructive  cases  reported  are  those  of 
Lockstaedt.1  In  his  Case  5  there  was  a  diffuse  myomatous  thick- 
ening invading  the  posterior  and  part  of  the  anterior  wall.  At 
several  points  the  myoma  had  penetrated  the  outer  muscular  cover- 
ing and  sent  prolongations  as  far  as  the  peritoneum.     On  section 

1  Lockstaedt,  Paul:  Ueber  Vbrkommen  und  Bedeutung  von  Drusenschlauchen 
in  don  Myoraen  dos  Uterus.  Monatsschrifl  t'-  Geburtshulfe  und  Gynaekologie, 
1898,  Bd.  vii,  p.  1SS. 


4  ADENOMYOMA    OF    THE    UTERUS 

of  the  tumor  numerous  round  lumina  were  seen.  These  had  a 
diameter  of  2  mm.  In  the  fundus  were  six  roundish  depressions 
of  the  mucosa,  into  all  of  which  one  could  easily  pass  a  metallic 
sound,  and  a  bristle  could  be  inserted  for  a  distance  of  from  1  to 
1.8  cm.  into  the  myomatous  tissue.  These  canals  branched  with 
one  another  and  also  with  those  in  the  middle  of  the  tumor.  All 
were  lined  with  a  clear  membrane  which  was  easily  loosened  from 
the  underlying  myomatous  tissue.  In  short,  the  small  canals  in 
the  myomatous  tissue  were  channels  from  the  uterine  cavity  and 
had  a  lining  of  uterine  mucosa. 

In  his  Case  7  Lockstaedt  found  a  diffuse  myomatous  thickening 
of  the  posterior  wall  and  of  the  right  side  of  the  uterus.  Near  the 
fundus  he  saw  five  roundish  depressions  of  the  mucosa,  and  from 
these  it  was  possible  to  pass  into  the  myoma  for  a  distance  of  1.5  cm. 
One  of  the  canals  was  broad  enough  to  be  easily  opened  with  the 
scissors,  and  here  one  could  see  that  the  mucous  membrane  was 
directly  continuous  with  that  of  the  uterine  cavity.  Scattered 
throughout  the  diffuse  growth  were  many  cyst  spaces,  most  of  them 
filled  with  reddish-brown  or  chocolate-colored  fluid.  In  order  to 
determine  whether  these  also  communicated  with  the  uterine  cavity, 
Lockstaedt  introduced  a  solution  of  Berlin  blue  into  all  of  them, 
and  was  thus  enabled  to  show  that  isolated  cyst  spaces  were  indirectly 
connected  with  the  uterine  cavity.  From  such  cases  we  see  that 
the  uterine  mucosa  penetrates  the  diffuse  myoma  at  several  points 
and  that  these  down-growths  branch  in  all  directions. 

In  Fig.  4,  p.  26,  we  see  just  the  earliest  stage  of  such  a  condition 
as  was  found  by  Lockstaedt.  Here  in  the  fundus  coarse  myomatous 
masses  are  welling  into  the  cavity  and  a  large  area  of  mucosa  is 
passing  down  into  the  crevice  between.  With  the  continued  growth 
of  the  myoma  a  portion  of  the  uterine  cavity  would  soon  be  drawn 
into  the  depth,  and  in  all  probability  would  eventually  lose  its 
continuity  with  the  parent  uterine  cavity. 

Rarely,  if  ever,  do  we  find  the  slightest  trace  of  glands  in  the 
outer  covering  of  normal  muscle.  In  the  majority  of  these  cases 
besides  the  diffuse  myomatous  growth  a  few  circumscribed  myomata 


DIKFl'SK    ADKXO.MYO.MA    OF    THE    DTER1   -  5 

are  present.  These  are  irregularly  scattered,  being  submucous, 
interstitial,  or  subperitoneal.  They  are  usually  only  a  few  centi- 
metres in  diameter,  hut  many  attain  to  1")  cm.  or  more  before  the 
uterus  is  removed.  When  the  uterus  is  not  enlarged,  the  uterine 
cavity  generally  presents  the  usual  appearance  and  is  in  no  way 
altered,  as  the  diffuse  myoma  does  not  usually  press  inward,  as  a 
submucous  myoma  invariably  does.  Case  27.~)4,  however,  is  an 
exception  (Fig.  8,  p.  42).  Here  there  is  a  considerable  bulging 
into  the  cavity. 

The  uterine  mucosa  is  usually  smooth,  save  for  the  occasional 
depressions  as  noted  in  Lockstaedt's  eases;  it  is  of  the  usual  breadth 
or  may  reach  a  thickness  of  from  7  to  8  mm.,  as  is  seen  in  Fig.  1, 
p.  10,  and  Fig.  23,  p.  77.  Polypi,  so  common  in  cases  of  discrete 
myomata,  are  usually  absent. 

Histological  Appear  a  nces  . — The  surface  of  the 
mucosa  is  usually  smooth  and  has  an  intact  surface  epithelium 
I  Fig.  6,  p.  37,  Fig.  14,  p.  56,  and  Fig-.  24,  p.  78).  The  glands  present 
the  normal  appearance  as  seen  in  Fig.  3,  p.  19,  and  Fig.  7,  p.  38. 
The  stroma  of  the  mucosa  just  beneath  the  surface  epithelium  is 
often  slightly  edematous  or  rarefied.  The  diffuse  thickening  in 
the  uterine  walls  consists  of  characteristic  myomatous  tissue,  the 
muscle  bundles,  however,  showing  much  more  interlacing  than  is  found 
in  the  ordinary  discrete  myomata.  Along  the  outer  or  advancing 
margin  of  the  growth  the  myomatous  cells  gradually  and  imper- 
ceptibly merge  into  the  normal  muscle  cells.  The  myomatous 
tissue,  as  was  noted  macroscopically,  extends  up  to  but  usually 
does  not  encroach  upon  the  mucosa.  In  most  cases  the  mucosa 
can  be  seen  dipping  down  into  the  diffuse  myomatous  growth,  and 
at  such  points  the  muscle  bundles  run  at  right  angles  to  the  mucosa, 
thus  allowing  the  latter  to  dip  down  between  them.  Sometimes  a 
single  gland  penetrates  the  myoma.  Such  a  gland  presents  a 
perfectly  norma]  appearance  (Fig.  20,  p.  92),  and  is  usually  accom- 
panied by  the  stroma  of  the  mucosa  which  separates  it  from  the 
muscle.  In  favorable  sections  such  a  gland  can  be  traced  far  into 
the  myomatous  tissue.     If  it  meets  a  barrier  in  the  form  of  a  muscle 


6  ADENOMYOMA    OF    THE    UTERUS 

bundle  running  parallel  with,  instead  of  at  right  angles  to,  the  uterine 
mucosa,  it  is  deflected  along  the  surface  of  this  until  other  muscular 
bundles  are  encountered  that  are  again  at  right  angles  to  the  uterine 
cavity.     It  then  passes  still  further  outward  between  them.     In  other 
words,  the  gland  follows  the  path  of  least  resistance,  winding  in  and 
out  in  all  directions  like  a  rivulet,  but  always  making  toward  the 
peritoneal    surface.     While    single    glands    sometimes    penetrate, 
larger  portions  of  the  mucosa,  as  a  rule,  find  their  way  into  the  muscle ; 
for  example,  in  Fig.  16,  p.  58,  three  glands,  accompanied  by  their 
stroma,  can  be  seen  extending  into  the  muscle  and  spreading  out 
in  the  depth,  where  more  room  is  met  with.     In  other  words,  they 
form  a  funnel  with  its  smaller  calibre  directed  toward  the  mucosa. 
In  Case  3136  the  mucosa  (Fig.  24,  p.  78)  invades  en  masse,  while 
in  Fig.  6,  p.  37,  and  in  Fig.  7,  p.  38,  the  mucosa  is  seen  penetrating 
as  the  roots  of  a  tree,  there  being  a  main  trunk  with  many  rootlets 
piercing  the  myoma  in  all  directions.     These  glands  retain  their 
normal  appearance  and,  as  can  be  noted  from  the  drawings,  are  invari- 
ably surrounded  by  the  normal  stroma  of  the  mucosa.     These  exten- 
sions of  the  normal  mucosa  in  many  cases  can  be  traced  by  direct  con- 
tinuity for  at  least  1  cm.     In  Fig.  6,  p.  37,  they  can  be  followed  for 
over  1.5  cm.     Of  course,  with  the  windings  in  and  out  of  the  down- 
growths  of  the  mucosa  the  continuity  will  be  lost  in  the  depth. 
Nevertheless,  serial    sections  and  injection  in    favorable  cases,   as 
carried  out  by  Lockstaedt,  show  that  the  bunches  of  glands  found 
in  the  depth  are  direct  extensions  from  the  mucosa.     In  the  out- 
lying portions  of  the  diffuse  myoma  round,   oval,   triangular,   or 
irregular  islands  of  glandular  tissue  are  encountered.     These  consist, 
as  a  rule,  of  essentially  normal  uterine  glands  (Fig.  14,  p.  56),  lined 
with  one  layer  of  cylindrical  ciliated  epithelium  and  surrounded  by 
the  normal  stroma  of  the  mucosa. 

Not  infrequently  these  glands  become  cystic,  the  dilatation 
varying  from  1  to  9  or  more  millimetres  in  diameter.  Such  dilata- 
tions are  easily  explained  by  the  kinking  and  bending  to  which  the 
glands  are  subjected  by  the  surrounding  and  ever-growing  myoma- 
tous tissue.     The  epithelium  of  the  dilated  glands  is  usually  pale- 


DIFFUSE    A  I) i:\o.\lYo.\I  A    OF   THE    I  TER1  -  / 

staining    and    somewhal    flattened.     The    cysl    Bpaces    frequently 

contain  desquamated  epithelium,  sometimes  are  partially  filled 
with  blood  pigmenl  and  also  contain  a  varying  quantity  of  blood. 
In  several  instances  we  have  noted  round  giant  cells  containing 
from  four  to  eight  nuclei  in  their  centres  and  probably  originating 
from  the  coalescence  of  degenerated  epithelial  cells.  Some  of  the 
large  spaces  are  not  dilated  glands,  but  represent  cross-sections  of 
the  deep  depressions  from  the  mucosa,  as  noted  in  Lockstaedi  's 
cases.  Here  the  entire  mucosa  is  carried  into  the  myoma,  and  on 
cross-section  we  have  a  space  lined  with  one  layer  of  surface  epithelium 
and  surrounded  by  typical  uterine  mucosa.  Of  course,  the  mucosa 
on  one  side  may  be  thinned  out  on  account  of  the  irregular  stretching 
of  the  myomatous  tissue,  and  then  we  have  a  picture  corresponding 
to  the  chief  canal — the  Hauptkanal  of  von  Recklinghausen.  The 
miniature  uterine  cavit}^  seen  in  Fig.  21,  p.  72,  although  situated  near 
the  peritoneal  surface,  is  probably  similar  in  origin.  From  the 
pathological  description  it  is  seen  that  the  uterine  glands  were 
found  extending  into  the  diffuse  myoma;  and  again,  a  reference  to 
Fig.  22,  p.  74,  w7hich  is  an  enlargement  of  a  portion  of  Fig.  21,  shows 
a  mucous  membrane  indistinguishable  from  that  lining  the  uterine 
cavity — a  mucosa  that  is  peculiar  to  the  uterus  and  never  found 
elsewhere.  The  glands  in  the  diffuse  myoma  occasionally  show 
some  branching,  as  noted  in  Fig.  16,  p.  58,  Fig.  22.  p.  74,  Fig.  26, 
p.  81.  This  finding  is  sometimes  noted  in  a  normal  uterus,  and  here, 
where  the  mucosa  has  such  free  play  and  where  the  glands  are  so 
long,  we  would  naturally  expect  some  branching.  On  the  whole, 
however,  they  are  remarkable  for  their  regular  shape. 

The  glands  are  naturally  most  abundant  in  the  vicinity  of  the 
mucosa;  they  gradually  diminish  in  number  in  the  outer  myomatous 
zone  and  are  completely  wanting  in  the  normal  outer  muscular 
capsule.  In  short,  where  the  myoma  ends  they  cease.  This  is 
well  shown  in  Fig  3,  p.  19,  Fig.  6,  p.  37,  Fig.  9,  p.  43.  and  Fig.  24. 
p.  78.  In  some  cases,  although  the  glands  in  the  diffuse  myoma  are 
identical  with  uterine  glands,  their  origin  from  the  mucosa  cannot 
be  clearly  proved.     In  the  majority  of  these  cases,  however,  careful 


8  ADENOMYOMA    OF    THE    UTERUS 

examination  of  serial  sections  will  show  that  at  several  points  at  least 
the  glands  of  the  mucosa  are  continuous  with  those  in  the  depth. 

CASES  OF  DIFFUSE  ADENOMYOMA  IN  WHICH  THE  UTERUS  RETAINS  A 
RELATIVELY  NORMAL   CONTOUR 

Had  we  been  told  several  years  ago  that  in  an  examination  of 
1283  myomatous  uteri  diffuse  adenomyomata  were  found  73  times, 
that  is,  in  about  5.7  per  cent.,  we  should  certainly  have  been  tempted 
to  doubt  the  veracity  of  the  author.  Nor  can  such  a  statement 
even  now  be  accepted  without  ample  proof.  Accordingly  it  has 
been  deemed  advisable  to  give  the  essential  features  of  each  of  the 
cases.  In  the  brief  description  which  we  have  just  given  of  this 
disease  only  the  salient  points  were  discussed.  Many  other  inter- 
esting data  may  be  gleaned  from  a  careful  perusal  of  the  individual 
records. 

Gyn.  No.  3418.    Path.  No.  661. 

Diffuse  adenomyoma  of  the  posterior 
uterine    wall  (Figs.  1  and  2). 

K.  B.  N.,  married,  aged  forty,  white.  Admitted  April  3, 
1895.  Complaint  on  admission:  Painful  and  profuse  menstruation. 
The  patient  began  to  menstruate  when  fourteen  years  of  age.  The 
periods  occurred  at  intervals  of  from  three  to  four  weeks,  were 
profuse,  but  not  accompanied  by  much  pain.  She  has  been 
married  seventeen  years;  had  one  difficult,  but  non-instrumental, 
labor  sixteen  years  ago,  after  which  she  was  confined  to  bed  for  six 
weeks  on  account  of  chills  and  fever,  which  were  followed  by  ab- 
dominal pains.  Eleven  years  ago  she  had  a  miscarriage.  Immedi- 
ately after  the  birth  of  the  child  the  menses  became  profuse  and  there 
was  a  discharge  of  dark,  clotted  blood.  Pain  was  felt  in  the  lower 
abdomen,  also  in  the  back.  It  commenced  a  few  hours  before  the 
flow  and  lasted  until  the  menses  were  over.  The  patient  has  never 
been  strong;  when  twelve  years  of  age  she  had  malaria,  and  when 
fifteen,  pneumonia.  Her  family  history  on  both  sides  is  decidedly 
tuberculous,  both  grandfathers,  her  mother,  one  aunt,  and  two 
cousins  having  died  of  phthisis. 


DIFFUSE     \l)i;\o\n  mm  \    OF   Till:    UTERUS  '.» 

Present  Condition.  The  patient  is  ,-i  well-nourished 
but  rather  anaemic  woman,  weighing  llo  pounds.  Her  tongue 
is  coated;  appetite  good.  She  has  an  occasional  headache;  ex- 
periences do  difficult y  in  locomol  ion ;  her  feel  and  ankles  occasionally 
swell;  urine  normal;  the  last  menses  ceased  two  weeks  ago  after  a 
duration  of  ten  days.  On  vaginal  examination  myoma  uteri  was 
diagnosed. 

April  6,  1  cS  9  5  .  Operation.  An  incision  L5  cm.  long 
was  made  in  the  median  line,  and  the  tumor  lifted  out  of  the  pelvis. 
The  ovarian  vessels,  round  ligaments,  and  uterine  vessels  were 
tied  and  the  uterus  was  amputated  low  down.  The  cervical  lips 
were  then  brought  together,  and  the  peritoneum  from  the  posterior 
pelvic  wall  was  united  with  that  from  the  anterior.  The  patient 
was  discharged  May  3d  feeling  perfectly  well. 

Gyn.-Path.  X  o  .  6  6  1  . — The  specimen  consists  of  the 
enlarged  uterus  with  its  appendages  intact.  The  uterus  is  pear- 
shaped  and  measures  12  cm.  in  length,  10  cm.  in  breadth,  and  8  cm. 
in  thickness.  It  is  pinkish  in  color,  smooth  and  glistening.  A 
portion  of  the  cervical  canal  measuring  2  cm.  in  length  is  present ; 
its  mucosa  is  pearly  white  in  color,  smooth  and  glistening,  and  has 
almost  entirely  lost  its  rugous  appearance.  The  uterine  cavity 
measures  4.5  cm.  in  length  and  is  5.5  cm.  in  breadth  in  its  upper 
portion.  The  posterior  wall  bulges  slightly  into  the  cavity.  The 
mucous  membrane  is  smooth,  but  presents  a  mottled  appearance, 
being  the  seat  of  extensive  hemorrhage.  It  is  S  mm.  in  thickness. 
The  anterior  uterine  wall  averages  2.5  mm.  in  thickness.  The 
posterior  wall  is  5  cm.  thick  an  d  maybe  d i - 
v  i  d  e  d  into  two  portions:  a  n  i  n  n  e  r  a  n  d  t  h  i  c  k  - 
e  n  e  d  ,  w  h  i  c  h  is  coarsely  striate  d  a  n  d  which 
looks  ver  y  m  u  c  h  1  i  k  e  m  y  o  m  a  t  o  u  s  tissue,  a  n  d 
a  n  outer,  r  e  s  e  m  b  1  i  n  g  n  o  r  m  a  1  u  1  e  r  i  n  e  m  u  s  c  1  e 
(Fig.  1).  The  contrast  is  much  sharper  after  the  specimen  has  been 
hardened  in  Midler's  fluid,  the  coarsely  striated  portion  staining 
lightly,  the  normal  muscle  deeply. 

On    careful    examination    of    the    hardened    specimen,    grayish- 


10 


ADENOMYOMA    OF    THE    UTERUS 


brown  granular  areas  are  seen  scattered 
portion   of    the    wall.     These   are   round 


Fig.  1. — Diffuse  adenomtoma  of  the  posterior  wall 
of  the  uterus.  (Natural  size.) 
Gyn.-Path.  No.  661.  The  uterus  has  been 
amputated  through  the  cervix.  The  anterior  uterine 
wall  is  unaltered.  The  posterior  wall  from  cervix  to 
fundus  is  greatly  thickened,  owing  to  the  presence  of  a 
diffuse  myomatous  growth  lying  between  the  mucosa  and 
the  outer  covering  of  normal  muscle.  This  diffuse  growth 
consists  of  fibres  forming  whorls  but  also  passing  in  all 
conceivable  directions.  It  encroaches  to  a  slight  extent 
on  the  uterine  cavity.  At  a  is  seen  the  junction  between 
the  diffuse  myoma  and  the  normal  muscle.  The  fibres 
of  the  one,  however,  blend  imperceptibly  with  the  other, 
and  it  would  be  impossible  to  shell  this  growth  out,  as 
can  be  done  with  discrete  myomata.  Near  the  internal 
os  is  a  small  polyp.  The  uterine  cavity  is  somewhat 
lengthened.  The  mucosa  lining  the  anterior  wall  is  of 
the  normal  depth,  but  that  covering  the  posterior  wall 
is  considerably  thickened,  and  at  two  points  indicated  by 
b  it  can  be  traced  for  a  considerable  distance  into  the 
myoma.  At  c,  just  along  the  lower  margin  of  the  growth, 
the  mucosa  can  be  seen  penetrating  into  the  uterine  wall 
for  fully  1.5  cm.  (For  the  histological  appearance  of  the 
posterior  wall  see  Fig.  2.) 


throughout  the  thickened 
or  irregular  in  contour, 
and  as  one  approaches 
the  uterine  cavity  are 
seen  to  merge  directly 
into  the  mucosa.  Even 
on  macroscopic  examina- 
tion it  is  evident  that 
at  least  in  the  superficial 
areas  are  portions  of  the 
mucosa  that  dip  down 
into  the  tumor. 

Scattered  here  and 
there  throughout  the 
tumor  are  cavities,  the 
largest  of  which  is  about 
5  mm.  in  diameter.  They 
have  a  smooth,  glisten- 
ing inner  surface.  Some 
of  them  are  filled  with 
blood.  Along  one  mar- 
gin of  the  tumor  is  a 
myomatous  nodule  1  cm. 
in  diameter.  The  outer 
portion  of  the  uterine 
wall,  which  corresponds 
to  the  uterine  muscle, 
averages  1  cm.  in  thick- 
ness. 

Right  side :  The  tube 
is  9  cm.  long,  6  mm.  in 
diameter.  It  is  free 
from  adhesions  and  has 
a  patent  fimbriated  ex- 
tremity. The  parovarium 


lUHTSK    ADKXOMVO.MA    OF    THE     UTERI    -  11 

is  intact.     The  ovary  is  3.5  by  2.5  by  L.8cm.      It  is  free  from  adhe- 
sions, and  on  its  under  surface  contains  two  slightly  dilated  Graafian 

follicles. 

Left  side:  The  tube  is  7  cm.  long  and  .8  cm.  in  diameter. 
It  is  free  from  adhesions  and  has  a  patent  fimbriated  extremity. 
The  parovarium  is  intact. 

The  ovary  is  3.5  by  2.5  by  .5  cm.  and  is  slightly  cirrhotic.  On 
its  under  surface  is  a  corpus  luteum,  2.5  by  1  cm. 

Histological  E  x  a  m  i  n  a  t  io  n  . — The  cervical  glands 
are  in  most  places  normal,  but  here  and  there  have  proliferated. 
The  epithelium  covering;  the  surface  of  the  cervical  mucosa  is  of  the 
high  cylindrical  variety;  near  the  junction  of  the  internal  os,  how- 
ever, it  suddenly  changes  and  the  mucosa  is  covered  with  several 
layers  of  squamous  epithelium.  Above  this  point  the  typical 
cervical  epithelium  is  again  found.  The  mucosa  covering  the  pos- 
terior wall  of  the  uterus  has  an  intact  surface  epithelium.  Here 
and  there  little  knob-like  masses  of  the  mucosa  project  into  the 
uterine  cavity.  The  uterine  glands  in  the  superficial  portion  are 
moderate  in  number  and  are  small  and  round  on  cross-section.  In 
the  deeper  portions  they  show  considerable  branching,  and  in  some 
places  it  looks  as  if  one  gland  gave  off  three  or  four  branches;  this 
appearance  is  probably  due  to  a  marked  convolution  of  the  glands. 
In  several  places  the  glands  are  seen  extend- 
ing down  into  the  underlyi  n  g  t  n  m  o  r  .  T  h  i  s 
is  most  noticeable  near  the  upper  p  a  i'  t  of  the 
uterine  cavity,  where  Ion  g  i  t  u  d  i  n  a  1  sections 
of  two  or  three  glands  can  be  seen  p  a  s  s  i  n  g 
b  e  t  w  een  m  u  s  c  1  e  bundles  into  t  h  e  d  e  p  t  h  o  f  t  h  e 
tumor.  This  is  clearly  demonstrable  to  the  naked  eye.  The 
stroma  is  rarefied  (Fig.  2). 

The  individual  stroma  cells  have  oval  vesicular  nuclei  and  are 
slightly  swollen.  Scattered  here  and  there  throughout  the  stroma 
are  small  round  cells  occurring  either  singly  or  in  clumps.  The 
superficial  portions  of  the  mucosa  show  considerable  hemorrhage. 
The  coarsely  striated  thickening  in  the  posterior  wall  is  composed 


12 


ADENOMYOMA    OF    THE    UTERUS 


A.  Horn-, 


Fig.  2. — Diffuse  adenomyoma  of  the  posterior  uterine  wall.     (3  diameters.) 

Gyn.-Path.  No.  661.  The  section  represents  the  upper  half  of  the  posterior  wall  of 
the  uterus  seen  in  Fig.  1.  The  wall  is  divided  into  three  distinct  zones,  an  inner,  a,  consisting  of 
the  uterine  mucosa;  a  middle  zone,  b.  thick  and  coarse,  made  up  of  diffuse  myomatous  tissue;  and 
an  outer  zone,  c,  composed  of  normal  muscle.  The  mucosa,  although  increased  in  thickness,  is 
normal.  The  surface  epithelium  is  intact  and  the  glands  present  the  usual  appearance.  The 
diffuse  myomatous  growth  has  many  islands  of  glands  scattered  throughout  it.  These  consist 
of  practically  normal  uterine  glands  and  are  surrounded  by  the  characteristic  stroma  of  the  mucosa. 
Some  of  the  glands  are  much  dilated.  Occasionally  a  gland  occurs  singly  and  lies  in  direct  contact 
with  muscle.  At  e  the  gland  has  retracted  from  the  surrounding  stroma.  The  origin  of  the  gland 
elements  in  this  diffuse  myoma  is  clear,  as  at  d  we  see  the  uterine  mucosa  extending  directly  into 
the  myoma. 


DIFFUSE    AI)i;.\o.MV().MA    OF   THE    UTERI  -  13 

of  non-striped  muscle  fibres,  which  are  cul  Longitudinally  and  trans- 
versely. This  tissue  is  denser  than  normal  uterine  muscle,  but 
otherwise  closely  resembles  it.  Between  the  bundles  of  muscle 
fibres,  and  also  between  the  individual  fibres,  there  is  considerable 
infiltration  with  small  round  cells.  Scattered  freely  throughoul 
the  tumor  are  glands.  The  majority  of  these  are  found  in  groups; 
some,  however,  occur  singly.  In  many  places  they  are  seen  on 
cross-section,  where  they  appear  as  rows  of  oval  or  round  glands. 
Some  have  been  cut  longitudinally  and  are  cylindrical;  others  are 
curved.  A  few  appear  to  have  secondary  glands  opening  into  them. 
The  glands  as  a  whole  are  lined  with  one  layer  of  cylindrical  epithe- 
lium, on  which  it  is  possible  in  many  places  to  make  out  cilia.  A 
few  of  them  are  dilated.  The  epithelium  of  some  is  intact  ;  in  others 
it  has  become  flattened  or  has  disappeared.  Some  of  the  dilated 
glands  are  empty,  others  contain  desquamated  epithelium  and 
granular  material.  Some  of  the  desquamated  cells  are  swollen  and 
their  protoplasm  contains  yellowish-brown,  granular  pigment. 

The  largest  gland  is  filled  with  blood.  In  many  of  the  glands 
the  epithelium  has  become  desquamated,  and  the  gland  is  only 
recognized  as  a  space  partially  or  completely  filled  with  desquamated 
cells.  The  groups  of  glands,  and  also  most  of  those  occurring  singly. 
are  surrounded  by  stroma  which  separates  them  from  the  muscle. 
This  stroma  is  similar  to  that  of  the  normal  uterine  mucosa.  Here 
and  there  cross-sections  of  three  or  four  glands  are  seen  where  the 
epithelial  cells  lie  directly  in  contact  with  the  muscle.  In  a  good 
many  places  stroma  cells  contain  brown,  granular  pigment.  At 
one  or  two  points  a  very  curious  picture  is  noted.  At  one  end  of  a 
space  between  muscle  bundles  it  is  possible  to  make  out  a  gland 
undergoing  degeneration;  on  tracing  this  a  little  further,  we  see 
three  oval  spaces  forming  a  chain;  these  are  almost  completely 
filled  with  small,  round  cells  and  cells  having  oval  vesicular  nuclei. 
which  look  a  little  like  those  of  epithelioid  cells.  Each  of  these 
masses  of  cells  contains  one  or  more  giant  cells,  which  are  round. 
oval,  or  elongated-oval;  their  nuclei  are  vesicular  and  situated 
in  the  centre  of  the  cell  or  around  the  periphery.     They  remind  one 


14  ADENOMYOMA   OF    THE    UTERUS 

somewhat  of  tubercles,  but  we  believe  them  to  be  degenerated 
glands.  No  tubercle  bacilli  could  be  detected  in  these  areas;  nor 
was  there  any  caseation. 

There  is  no  definite  arrangement  of  the  muscle  around  the 
bunches  of  glands.  It  looks  as  if  the  glands  just  filled  in  the  spaces 
between  muscle  bundles.  At  one  side  of  this  new  growth  is  a  typical 
myomatous  nodule,  1  cm.  in  diameter;  this  is  entirely  devoid  of 
gland  elements.  The  outer  zone  of  the  posterior  wall,  consisting 
of  uterine  muscle,  is  normal.  The  mucosa  covering  the  anterior 
uterine  wall  is  normal.     Both  tubes  and  ovaries  are  normal. 

Gyn.  No.  12,681.     Path.  No.  9517. 

Diffuse  myomatous  thickening  of  both 
anterior  and  posterior  uterine  walls;  large 
polyp  in  the  body  of  the  uterus;  diffuse  adeno- 
myoma  of  the  posterior  wall;  slight  adeno- 
myomatous  tendency  in  the  anterior  wall. 

F.  Y.,  married,  aged  fifty-nine,  white.  Admitted  Feb.  7,  1906; 
discharged  March  12,  1906.  The  menses  commenced  at  fourteen 
and  were  regular  until  ten  years  ago.  At  this  time  the  periods 
became  irregular  and  were  from  three  to  seven  weeks  apart.  The 
flow  is  now  more  profuse  and  there  is  flooding.  The  patient  has 
had  pain  in  the  region  of  the  uterus  for  some  time.  The  last  period 
came  on  three  weeks  ago.  The  patient  has  been  married  thirty- 
nine  years,  has  had  eight  children  and  two  miscarriages.  The 
oldest  child  is  thirty-eight,  the  youngest  twenty.  Two  years  ago 
she  consulted  a  physician,  who  removed  several  small  polypi  from 
the  cervical  canal.  The  bleeding  diminished  somewhat  after  this, 
but  has  been  increasing  again  of  late,  and  is  now  as  abundant  as 
before  the  operation.  The  patient  has  had  no  pain  except  a  feeling 
of  dull  aching  about  the  bladder.  She  is  constipated.  There  is 
shortness  of  breath  and  a  slight  increase  in  frequency  of  micturition. 

Protruding  from  the  os  is  a  polyp  5  mm.  in  diameter.  The 
fundus  is  not  definitely  outlined. 

Operation . — Removal  of  small  cj^st  from  the  left  labium 


DIFFUSE    ADENOMYOMA    OF    THE    UTERUS  LO 

tnajus;  hysterectomy;  double  salpingo-oophorectomy.  The  pa- 
tient's highest  temperature  was  L00.8  1".  She  made  an  uneventful 
recovery  except  for  a  superficial  breaking  down  of  the  incision. 

P  a  1  h  .  X  o  .  9  51  7. — The  specimen  consists  of  a  myomatous 
uterus  10  cm.  in  length,  9  cm.  in  breadth,  and  8  cm.  in  its  antero- 
posterior diameter.  It  is  smooth  and  glistening.  The  anterior 
wall  varies  from  3.5  to  4  cm.  in  thickness  and  presents  a  coarse 
striated  appearance.  In  the  fundus  is  a  discrete  myoma  3  mm.  in 
diameter.  The  posterior  wall  varies  from  2.3  to  ?>  cm.  in  thickness. 
It  also  presents  a  rather  coarse  striation.  Just  to  the  left  of  the 
cervix  is  a  myoma  2.5  cm.  in  diameter,  and  below  the  cervix  i>  a 
myoma  approximately  6  cm.  in  diameter.  The  right  tube  offers 
nothing  of  interest.  The  ovary  is  covered  with  a  few  adhesions. 
It  is  very  small.  The  left  tube  is  normal.  The  ovary  is  somewhat 
mutilated.  The  mucosa  varies  from  2  to  4  mm.  in  thickness,  and 
projecting  from  the  left  side  is  a  polyp  2  cm.  in  length,  1  cm.  in 
thickness. 

Sections  taken  from  the  posterior  wall  show  an  intact  surface 
epithelium.  The  glands  are  normal.  The  stroma  presents  the 
usual  appearance.  The  most  striking  point  ob- 
served with  the  dissecting  microscope  is  t  h  a  t 
a  t  m  any  p  o  i  n t  s  the  g 1  a  n  d  s  c  a  n  b e  trace  d 
into  the  depth.  At  one  point  the  y  can  1  >  e 
followed  by  continuity  for  3  mm.  In  other 
places  several  glands  run  down  in  the  form  of  a  funnel.  Scattered 
throughout  the  thickened  diffuse  myomatous  wall  are  glands  and 
islands  of  uterine  mucosa.  Some  of  them  contain  only  a  single 
gland,  others  cross-sections  of  eight  or  more.  Very  few  of  these 
glands  show  dilatation. 

Sections  from  the  anterior  wall  also  show  a  great  deal  of  diffuse 
thickening.  We  have  an  intact  surface  epithelium,  normal  glands, 
and  a  stroma  which  in  its  superficial  portion  shows  considerable 
hemorrhage.  At  several  points  far  down  in  the  depth  we  have 
a  few  isolated  glands.  There  is  here  an  adenomyomatous  ten- 
dency, which  is  not.  however,  very  marked.     In  the  anterior  wall 


16  ADENOMYOMA    OF    THE    UTERUS 

we  have   several  discrete  myomata,  the  largest  being   1.5  cm.  in 
diameter. 

Diagnosis  . — Diffuse  myomatous  thickening  of  both  anterior 
and  posterior  uterine  walls  with  marked  extension  of  the  mucosa 
into  the  posterior  wall  and  slight  penetration  of  the  uterine  mucosa 
into  the  anterior  wall;  discrete  myomata  chiefly  in  the  cervical 
tissue;  normal  appendages. 

Gyn.  No?  11,850.     Path.  No.  8197. 

Diagnosis:  Interstitial  and  subperitoneal 
uterine  myomata.  Diffuse  adenomyoma  in 
the  uterine  walls,  the  glands  originating 
in     the     mucosa. 

C.  B.,  aged  thirty-nine,  white,  married.  Admitted  January  30, 
1905. 

Complaint:  abdominal  tumor.  The  patient  had  one  child, 
eight  years  ago;  no  miscarriages.  Menses  at  sixteen.  Were 
regular  every  four  weeks.  Flow  lasted  four  days,  but  lately  has 
been  of  only  one  day's  duration.  Flow  very  scant,  with  clots. 
The  pain  was  formerly  cramp-like,  but  lately  only  slight.  There 
has  been  no  bleeding  since  the  last  period.  After  the  birth  of  the 
child,  eight  years  ago,  she  had  what  was  supposed  to  be  an  abscess 
of  the  uterus.  This  opened  spontaneously.  She  made  a  satis- 
factory recovery,  and  in  1900  she  had  a  second  abscess,  which 
opened  spontaneously. 

Operation  . — Hystero-myomectomy. 

The  uterus  was  small.  On  its  anterior  surface  was  an  irregular 
myomatous  tumor  about  18  by  5  cm.  The  tubes  and  ovaries  on 
each  side  were  very  much  adherent  from  a  chronic  inflammatory 
process.  The  myoma  was  first  bisected  and  loosened  from  the 
bladder.  The  uterus  was  removed  and  later  the  appendages.  The 
left  ovary  was  firmly  adherent  to  the  rectum.  In  cutting  it  away 
a  small  piece  of  ovarian  tissue  was  left  behind.  Convalescence  was 
not  complicated.  The  highest  temperature  was  100.4°  F.,  twenty- 
four  hours  after  operation. 


DIFFUSE    A.DEN0MY0MA    OF   THE    [JTERUS  1< 

Path.  No.  8  1  9  7.  The  specimen  consists  of  the  uterus 
amputated  above  the  cervix.  It  has  been  bisected.  Attached  to 
the  anterior  wall  is  a  large  interstitial  myoma.  Both  tubes  and  a 
pari   of  the  left   and  of  the  righl   ovary  are  present.     The  uterus 

is  normal  in  size.  Its  cavity  measures  4  cm.  in  Length.  Springing 
from  the  anterior  wall  of  the  uterus  is  a  myomatous  growth,  is  by 
5  cm.  The  tumor  does  not  encroach  at  all  upon  the  uterine  cavity. 
There  are  several  small  myomatous  nodules  scattered  throughout 
the  uterine  wall.  These  are  interstitial.  There  are  dense  adhesions 
over  the  surface  of  the  tumor.  The  right  tube  and  ovary  are  ad- 
herent. The  fimbriated  end  is  lost  in  the  tubo-ovarian  mass.  The 
left  ovary  is  cystic.  The  left  tube  is  normal.  Only  a  portion  of 
the  left  ovary  has  been  removed. 

Sections  from  the  endometrium  show  that  the  glands  are  perfectly 
normal  except  that  here  and  there  there  is  a  dilatation.  At  some 
points  there  is  a  distinct  tendency  for  the 
glands  to  extend  into  the  depth,  and  at  one 
point  we  h  a  v  e  definite  islands  of  mucosa  at 
least  4  mm.  from  the  surface.  A  direct  connection 
between  these  and  the  surface  mucosa  can  be  traced.  Around  these 
islands  the  muscle  showrs  a  definite  myomatous  tendency.  Sections 
from  one  of  the  myomata  yield  the  usual  appearance.  There  is 
some  hyaline  transformation. 

D  i  a  g  n  o  s  i  s  . — Interstitial  and  subperitoneal  uterine  myomata  : 
definite  adenomyoma  with  the  glands  originating  from  the  mucosa. 

Gyn.  No.  2573.     Path.  No.  163. 

Diffuse  a  d  e  n  o  m  y  o  m  a  0  c  c  u  p  y  i  n  <;■  both  the 
anterior  a  n  d  post  e  r  i  o  r  u  t  e  r  i  n  e  w  alls  I  Fig.  3  : 
discrete  subperitoneal,  interstitial  and  s  11  1  >  - 
m  u  c  o  u  s    m  y  o  m  a  t  a  .     H  y  s  t  e  r  e  c  t  0  in  y  .     R  e  c  0  v  e  r  y  . 

M.  B.,  married,  aged  fifty,  white.  Admitted  Feb.  7.  discharged 
March  10.  1894. 

The  patient  has  been  married  twenty-eighl  years  and  has  had 
five  children,  the  youngesl  of  whom  is  now  sixteen.     Flow  usually 


18  ADENOMYOMA    OF    THE    UTERUS 

returned  in  ten  months.  One  miscarriage,  thirteen  years  ago, 
at  six  weeks. 

Menses  irregular  until  marriage,  with  profuse  flow  and  some 
pain;  periods  regular  after  marriage.  Last  spring  the  menses 
began  to  decrease  gradually,  the  pain  also  became  less.  The  last 
period  occurred  in  June.  1893  (menopause?).  After  the  cessation 
of  the  flow  in  June.  1893.  the  patient  felt  very  well.  In  August, 
1893.  she  had  a  slight  flow  at  about  the  menstrual  period,  and  at 
this  time  commenced  to  feel  weak  and  to  have  a  profuse  yellowish 
leucorrhoeal  discharge.  Since  November,  1893,  she  has  had  constant 
hemorrhages. 

Examination  . — Douglas'  cul-de-sac  is  filled  with  a  hard, 
immovable  mass,  from  which  the  uterus  cannot  be  differen- 
tiated. 

Operation  .  Feb.  10,  1894.  Dilatation  and  curettage. 
Double  salpingo-oophorectomy.  Hystero-myomectomy.  Uterus 
dilated  and  curetted  with  removal  of  a  large  quantity  of  mushy 
endometrial  tissue.  Retroflexed  adherent  myomatous  uterus  re- 
moved. 

Maximum  temperature  100.8°  F.  on  eleventh  day.  Varied 
between  98.6°  and  100.5°  F.  for  over  three  weeks.       Recovery. 

Gyn.-Path.  N  o  .  16  3  . — The  specimen  consists  of  the 
uterus,  tubes,  and  ovaries.  The  uterus  is  uniformly  enlarged,  being 
8  cm.  in  length,  7  in  breadth,  and  about  7.5  in  its  antero-posterior 
diameter.  It  is  smooth  and  glistening,  but  situated  on  the  posterior 
surface  are  two  small,  hard  nodules  about  5  mm.  in  diameter.  These 
are  myomata.  The  anterior  uterine  wall  varies  from  2  to  3  cm.  in 
thickness.  Its  muscular  tissue  is  rather  coarse,  especially  in  its 
inner  half,  and  scattered  throughout  it  are  numerous  myomata, 
some  reaching  1.5  cm.  in  diameter.  The  posterior  uterine  wall 
varies  from  2  to  3.5  cm.  in  thickness.  Its  muscular  tissue  near  the 
uterine  cavity  is  coarse  in  texture.  Scattered  throughout  it  are 
several  small  myomata.  Some  of  these  encroach  to  a  slight  extent 
on  the  uterine  cavity.  The  uterine  cavity  is  7  cm.  in  length  and 
7.5  cm.  in  breadth  at  the  fundus.     A  description  of  the  mucosa  can 


DIFFUSE    A.DENOMYOMA    OF   THE    I  TER1  - 


19 


- 


Jf  £eckes>. 


—A 


Fig.  3. —  Diffuse  adenomyoma  of  the  posterioh  uterine  wall.     (3 J  diameters. 

Gyn.-Pal  h.  N  o  .  163.  The  section  is  taken  from  the  upper  pari  of  the  uterine 
cavity,  as  shown  by  the  position  of  ".  which  denotes  the  fundus.  The  uterine  walls  with  the 
higher  power  show  a  slight  myomatous  transformation.  There  is  considerable  encroachment 
of  the  growth  on  the  uterine  cavity.  At  b  the  mucosa  is  of  the  usual  thickness  and  is  normal  in 
appearance.  At  the  fundus  as  seen  al  c  it  is  thickened,  but  mechanically  injure, 1.  At  <1  t he 
mucosa  penetrates  the  diffuse  growth  torn  short  distance  and  at  d'  can  be  traced  far  into  the 
muscle.  At  the  latter  point  there  is  also  a  direct  communicat  ion  bel  ween  the  two  down-growths, 
e  is  a  cystic  uterine  gland.  Scattered  throughout  the  inner  half  *<\  the  uterine  wall  are  numerous 
islands  of  uterine  glands  surrounded  by  deeply  stained  areas     the  normal  stroma  of  the  mucosa. 

Here  and  there  is  a  small  gland  lying  in  direct  contact  with  the  muscle.      There  are  also  numerous 

deeply  stained  areas,  as  represented  by  /.     These  consist  of  stroma  of  the  mucosa  devoid  of  gland 

elements.      That  the  glands  of  this  growth  are  derivatives  of  the  uterine  glands  i-  evident. 


20  ADENOMYOMA    OF   THE   UTERUS 

be  of  little  value,  as  the  greater  portion  of  it  had  been  removed 
with  the  curette  prior  to  operation. 

Histological  Examination  . — Sections  from  pro- 
tected portions  show  that  the  surface  epithelium  is  intact.  The 
uterine  glands  present  the  usual  appearance ;  some  of  them,  however, 
are  considerably  dilated.  The  stroma  of  the  mucosa  presents  the 
usual  appearance.  On  the  whole,  we  should  consider  the  mucosa 
normal.  At  one  point,  however,  near  the  fundus  the  glands  show 
a  peculiar  branching  and  the  epithelium  is  somewhat  flattened, 
but  the  individual  cells  show  no  suspicious  changes.  The  diffuse 
thickening  in  both  the  anterior  and  posterior  walls  is  due  to  a  myo- 
matous transformation  of  the  muscle.  In  some  places  this  is  very 
pronounced,  but  it  is  to  a  great  extent  limited  to  the  inner  half  of 
the  uterine  walls.  In  many  places  the  mucosa  has 
penetrated  the  diffuse  myoma  for  a  distance 
of  1.5  cm.  and  in  several  places  the  direct 
extension  into  the  depth  can  be  traced  for 
a  distance  of  6  mm.  (Fig.  3).  In  the  depth  these  down- 
growths  of  the  mucosa  are  recognized  as  islands  of  mucous  membrane 
surrounded  by  myomatous  tissue.  These  islands  sometimes  contain 
a  dozen  or  more  glands,  normal  in  appearance  and  surrounded  by  the 
characteristic  stroma.  Some  of  the  glands  are  much  dilated,  and 
occasionally  an  isolated  gland  is  found  lying  between  muscle  bundles, 
but  even  then  it  is  usually  separated  from  the  muscle  by  the  stroma 
of  the  mucosa.  The  diffuse  adenomyomatous  condition,  although 
present  in  both  the  anterior  and  posterior  walls,  is  more  pronounced 
in  the  posterior.     Both  tubes  and  ovaries  are  normal. 

Diagnosis . — Diffuse  adenomyoma  occupying  both  the 
anterior  and  posterior  uterine  walls;  discrete  subperitoneal,  in- 
terstitial, and  submucous  myomata;  normal  appendages. 

H.  A.  K.  Sanitarium  No.  193 1.     Path.  No.  9367. 

Subperitoneal,  interstitial,  and  submu- 
cous uterine  myomata;  commencing  adeno- 
myoma. 


DIFFUSE    ADEN0MY0MA    OF   THE    UTERUS  -1 

J.  H.,  aged  forty-nine,  white.  Admitted  May  LI,  L905.  The 
patient  complains  of  an  excessive  flow.  In  L893  a  myoma  was 
diagnosed.  This  has  apparently  not  increased  in  size.  The  patient 
now  suffers  chiefly  from  pressure  on  the  bladder.  There  is  a  great 
deal  of  pain  in  the  region  of  the  left  ovary  and  in  the  lower  pari  of 
the  abdomen.  On  May  12,  1905,  with  a  pair  of  forceps,  a  myoma 
was  drawn  down  out  of  the  body  of  the  uterus.  Examination  per 
rectum  showed  that  the  tumor  was  the  size  of  a  cocoanut  and  that 
there  were  several  others.  She  soon  left  the  hospital,  hut  returned 
on  October  6th.     The  last  menstrual  flow  had  been  very  severe. 

Operation  Nov.  18,  1905  . — Hystero-myomectomy, 
right  salpingo-oophorectomy.  The  patient  made  a  very  satisfactory 
recovery. 

Path.  No.  936  7. — The  specimen  consists  of  the  uterus, 
which  is  rather  uniformly  enlarged,  and  which  lias  been  amputated 
through  the  cervix.  It  is  11  cm.  in  length,  12  cm.  in  breadth,  and 
12  cm.  in  its  antero-posterior  diameter.  Occupying  the  anterior 
wall  is  an  oval  mass,  8  by  6  cm.,  presenting  a  typical  myomatous 
appearance.  Scattered  throughout  the  uterine  walls  are  numerous 
interstitial  myomata,  and  there  are  also  two  submucous  nodules, 
the  larger  2.5  cm.  in  diameter.  The  uterine  mucosa  is  apparently 
very  thin.     The  right  tube  and  ovary  look  normal. 

Histological  examination  shows  the  endometrium 
to  be  perfectly  normal.  Over  the  surface  of  a  submucous  myoma 
from  the  fundus,  there  is  a  distinct  myomatous  thickening,  and 
covering  its  surface  is  an  intact  surface  epithelium.  R  i  d  d  1  i  n  g 
t  h  e  m  y  o  m  a  for  a  short  d  i  s  t  a  n  c  e  a  r  e  n  o  r  m  a  1 
u  t  e  r  i  n  e  g  lands,  some  of  w  h  i  c  h  s  h  o  w  a  d  i  r  e  C  I 
conn  e  c  t  i  o  n  w  i  t  h  the  ut  e  r  i  n  e  m  u  c  o  s  a  .  A  little 
further  on  are  two  small  myomata  projecting  into  the  cavity,  and 
on  either  side  of  them  is  normal  mucosa.  This  is  rather  remarkable, 
as  there  is  really  no  encroachment  upon  the  uterine  cavity,  the 
myomata  just  taking  the  place  of  the  normal  uterine  mucosa. 

Diagnosis. — Subperitoneal,  interstitial,  and  submucous 
uterine  myomata;  commencing  adenomyoma. 


22  ADENOMYOMA    OF    THE    UTERUS 

Gyn.  No.  12,599.     Path.  No.  9366. 

Slight  grade  of  endometritis,  diffuse  thick- 
ening of  both  the  anterior  and  posterior  uterine 
walls;  diffuse  adenomyoma  of  the  anterior  wall 
with    the   glands   originating   in   the   mucosa. 

S.  A.  B.,  married,  aged  forty -three,  white.  Admitted  January 
10,  1906;  discharged  January  31,  1906.  Complaint:  uterine 
hemorrhages.  The  menses  commenced  at  eleven  and  occurred 
every  three  or  four  weeks  until  a  year  ago.  Since  then  the  periods 
have  been  irregular  and  prolonged,  with  flooding,  at  times  accom- 
panied by  cramps,  which,  however,  have  not  been  severe.  Flow 
normal,  lasting  from  six  to  eight  days.  The  last  period  began  one 
month  ago  and  has  persisted  up  to  the  present  time.  The  patient  has 
been  married  twenty-one  years,  has  had  three  children  and  two 
miscarriages.     The  oldest  child  is  twenty,  the  youngest  fourteen. 

For  fourteen  years  the  patient  has  noticed  that  ten  days  after 
the  menses  the  abdomen  would  swell  markedly  and  she  would  have 
the  sensation  as  if  everything  were  falling  out  of  the  abdomen. 
Six  months  ago  she  had  her  menstrual  period  and  the  bleeding  per- 
sisted for  one  month;  it  could  not  be  controlled  with  medicine. 
Three  days  before  admission  the  bleeding  became  so  marked  that 
the  uterus  was  packed. 

Operation  . — Hysterectomy,  amputation  through  the  cer- 
vix. The  history  was  somewhat  suggestive  of  carcinoma,  and 
as  the  uterus  had  been  recently  curetted  we  prepared  to  do  an 
abdominal  hysterectomy,  if  necessary,  but  on  opening  the  abdomen 
noted  the  coarse  striated  appearance  of  the  uterus  and  consequently 
amputated  through  the  cervix.  The  patient  made  a  satisfactorj^ 
recovery.     The  highest  post-operative  temperature  was  100°  F. 

Path.  No.  9366  . — The  specimen  consists  of  the  uterus 
amputated  through  the  cervix  and  of  the  appendages  on  both  sides. 
The  portion  of  the  uterus  present  is  7  cm.  in  length,  8  cm.  in  breadth, 
and  6.5  cm.  in  its  antero-posterior  diameter.  Anteriorly  it  is 
smooth  and  glistening.  Posteriorly  it  is  covered  with  a  few  adhe- 
sions.   The  uterine  walls  are  firm.    The  posterior  wall  varies  from  2.5 


DIFFUSE    ADENOMYOMA    OF   THE    UTERI   -  23 

to  3  cm.  in  thickness.  The  anterior  also  reaches  3  cm.  in  diameter. 
The  mucosa  is  apparently  thin  on  the  posterior  wall  and  on  the 
anterior  reaches  2.5  mm.  in  thickness.    Therighl  tube  is  covered  with 

a   few  adhesions.     Its  fimbriated  end   is  patent.     The  righl  ovary, 

apart  from  a  few  adhesions,  is  normal.  The  left  tube  is  normal. 
The  left  ovary  is  slightly  adherent. 

S  e  c  t  i  o  n  s  f  r  o  m  1  h  e  a  n  t  e  r  i  o  r  u  t  e  r  i  n  e  w  a  1  1 
show  t  h  a  t  it  is  r  i  d  d  1  e  d  w  i  1  h  is]  ;i  n  d  s  o  f  n  I  e  r  i  n  e 
mucosa.  In  a  good  many  places  these  islands  are  irregular 
and  are  surrounded  by  a  zone  of  muscle  fibres  lying  parallel  with 
the  islands.  External  to  this  parallel  zone  is  a  circular  zone.  In 
a  good  many  places  the  glands  occurring  in  the  muscle  are  dilated 
and  at  numerous  points  are  seen  miniature  cavities.  These  are 
lined  with  one  layer  of  epithelium  resting  on  the  underlying  stroma, 
in  which  typical  uterine  glands  are  situated.  The  myomatous 
tissue  forming  this  diffuse  growth  is  not  very  sharply  differentiated 
from  normal  uterine  muscle.  Some  of  the  glands  have  two  layers 
of  cells  which  stain  palely,  and  the  appearances  are  rather  suggestive 
of  pathological  changes.  It  will  be  noted  that  the  glands  in  such 
an  adenomyoma  might  very  readily  have  undergone  carcinomatous 
changes. 

On  examining  further  sections  it  is  found 
t  h  a  t  the  mucosa  of  the  a  n  t  e  r  i  o  r  w  all  can  1  >  e 
traced  into  the  depth  for  1.5  cm.  Here  it  ends 
abruptly.  The  endometrium  shows  numerous  polymorphonuclear 
leucocytes.  The  posterior  wall  showrs  diffuse  myomatous  thickening 
but  contains  no  glands. 

D  i  a  gnosis  . — A  mild  grade  of  endometritis;  diffuse  myoma- 
tous thickening  of  the  anterior  and  posterior  uterine  walls;  definite 
adenomyoma  of  the  anterior  wall  with  the  glands  originating  from 
the  mucosa. 

Gyn.  No.  3614.     Path.  No.  788. 
Diffuse4       m  y  0  in  atous        t  h  i  c  k  e  n  i  n  g        of        t  h  e 
uterine    walls    w  it  li    extension    0  f    a    1  a  r  c  e    are  a 


24  ADBNOMTOMA    OF    THE    UTERUS 

of  mucosa  into  the  depth  between  the  myo- 
ma t  a  ( Fig.  4) .  Interstitial  uterine  myomata; 
hemorrhage  into  and  thickening  of  the  mucosa; 
general  pelvic  peritonitis. 

Mrs.  D.  G.,  aged  forty-three.  Admitted  June  29,  1895.  Com- 
plaint :  pain  in  the  lower  part  of  the  abdomen  and  profuse,  painful 
menstruation.  She  has  been  married  twenty-five  years,  but  has 
never  been  pregnant.  Menstruation  began  during  the  sixteenth 
year  and  continued  to  be  regular  until  five  years  ago.  It  has 
always  been  free  and  at  times  painful.  Her  family  history  is  nega- 
tive. At  seventeen  she  had  typhoid  fever  with  meningeal  symptoms, 
and  since  then  her  health  has  been  poor.  The  present  illness  dates 
back  five  years.  At  this  time  she  passed  several  dark,  tarry  and 
red  masses  from  the  vagina.  These  appeared  to  be  covered  with  a 
thin  membrane  and  their  passage  was  accompanied  b}r  paroxysms 
of  pain.  After  this,  menstruation  became  irregular  and  very  profuse, 
sometimes  lasting  two  weeks.  The  discharge  was  very  dark  in 
color  and  frequently  clotted.  About  the  second  day  of  menstrua- 
tion severe  pain  would  commence.  This  would  last  throughout 
the  period,  and  has  at  times  been  so  severe  that  it  was  necessary 
to  keep  her  under  the  influence  of  chloroform.  The  last  period 
came  on  four  weeks  ago,  the  one  before  that  six  months  previously. 
Four  weeks  ago  she  noticed  a  tumor  in  the  lower  part  of  the  abdomen. 
This  was  freely  movable. 

In  January,  1894,  an  exploratory  section  was  made.  Nothing- 
was  done,  as  the  tumor  was  supposed  to  be  malignant.  After  the 
operation  the  pain  diminished  and  the  patient  left  improved. 

Present  Condition  . — The  patient  is  emaciated  and 
anaemic,  the  tongue  is  clean,  the  bowels  are  constipated.  She  has  had 
a  watery  discharge  which  has  persisted  for  the  last  four  years.  This 
is  slightly  offensive  and  varies  considerably  in  color;  at  times  it  is 
yellow;  at  other  times  it  has  a  greenish  tinge.  It  is  often  tinged 
with  blood,  and  is  profuse.  Menstruation  is  frequent  and  at  times 
painful,  and  during  recent  years  there  have  been  sensations  of  weight 
and  pain  in  the  region  of  the  rectum.     Locomotion  and  exercise 


DIFFUSE    A.DEN0MY0MA    OF   THE    [JTER1  -  25 

occasion  a  greal  deal  of  pain  in  the  lower  abdomen.     Abdominal 

pressure,  however,  does  not  cause  any  discomfort. 

Operation  July    1,    L  8  9  5 .     After  breaking  up  numerous 

adhesions  to  the  anterior  abdominal  wall  the  uterus  could  be  lifted 
up.  It  was  amputated  from  left  to  righl  in  the  usual  manner  and  a 
drain  was  broughi  out  through  the  vagina.  On  the  second  day 
the  temperature  rose  to  100.6°  F.  For  several  days  it  ranged  be- 
tween 100°  and  101°  F.  On  July  15th  the  cervix  was  dilated,  and 
aboul  70  c.c.  of  pus  escaped.  On  the  twenty-fifth  day  the  tempera- 
ture reached  normal,  and  on  August  12th  the  patient  was  discharged 
feeling  perfectly  well.  The  abdominal  wound  in  this  case  broke 
down  and  discharged  for  a  few  days,  but  on  July  20th  had  healed 
completely. 

Path.  X  o  .  788  . — The  specimen  consists  of  the  uterus  with 
intact  appendages.  The  uterus  is  11  by  9  by  9  cm.  Anteriorly 
and  posteriorly  it  is  covered  with  dense  adhesions.  It  is  soft  and 
yielding  on  pressure.  The  uterine  cavity  measures  6  cm.  in  length 
and  6  cm.  in  breadth.  At  the  fundus  the  mucosa  is  bluish-red  in 
color,  very  irregular,  and  presents  numerous  nodules  which  vary 
from  1  to  3.8  cm.  in  diameter.  The  surface  of  the  mucosa  over 
some  of  these  nodules  is  smooth  and  glistening,  but  for  the  mosl 
part  it  presents  a  rough  appearance.  Over  the  fundus  are  numer- 
ous adhesions  passing  from  the  anterior  to  the  posterior  surface. 
The  mucosa  varies  from  1  to  7  mm.  in  thickness.  The  uterine 
muscle  averages  3  cm.  in  thickness.  Situated  in  the  anterior  wall 
is  a  firm  nodule,  1.5  cm.  in  diameter,  presenting  the  typical  myoma- 
tous appearance  (Fig.  4).  The  fundus  is  occupied  by  a  tumor 
approximately  9  cm.  in  diameter.  On  section  the  central  portion 
of  this  tumor  over  an  area  6.5  cm.  in  diameter  has  undergone  degen- 
eration. It  consists  of  a  soft,  yielding,  whitish  tissue  held  in  posi- 
tion by  delicate  bands. 

Plight  side:  The  tube  is  S  cm.  in  length.  It  is  covered  with 
dense  adhesions.  Its  fimbriated  end  is  patent.  The  ovary  is 
2.5  by  2.5  by  1  cm.  and  shows  a  dilated  follicle. 

Left  side:   The  tube  is  7  cm.  in  length  and  averages  5  mm.  in 


26 


ADENOMYOMA    OF    THE    UTERUS 


diameter.     It    is   free   from   adhesions.     The   ovary   is   small   and 
covered  with  delicate  vascular  adhesions. 


Fig.  i. — Diffuse  adexomtomatofs  thickening  in  the  fundus  and  posterior  uterine  ay  all 

WITH    EXTENSION    EX    MASSE    OF    THE  MUCOSA  IXTO  A  LARGE   CREVICE  BETWEEN   MYOMATOUS 

masses.      Natural  size.; 

Gyn.-Path.  X  o  .  7  8  8.  The  myoma  is  welling  into  the  uterine  cavity,  and  into 
the  space  between  myomatous  masses  a  large  area  of  mucosa  is  flowing.  With  the  continued 
growth  of  the  myomatous  tissue  this  mucosa  would  in  all  probability  be  nipped  off  and  carried 
outward,  thus  forming  a  large  island  of  mucosa  surrounded  by  myomatous  tissue. 


On  section  of  the  specimen  after  hardening  in  Mtiller's  fluid, 
the  uterine  walls  are  found  to  be  divided  into  two  distinct  kiyers. 


DIFFUSE    A.DENOMYOMA    OF   THE    [JTERUS  21 

In  the  anterior  wall  the  inner  layer  is  2  cm.  in  breadth.  This  differs 
from  the  outer  layers  and  docs  not  stain  as  deeply.  In  a  few  places 
small  myomata  ;ire  seen  scattered  throughout  the  thickened  pari 
of  the  wall.  Eighl  mm.  beneath  the  mucosa  is  an  area  of  mucous 
membrane  8  nun.  in  diameter.  In  some  places  the 
u  t  e r  i  n  e  m  u  c  o  s  a  c  an  l>  e  s  e  e  n  f  1  o  w  i  n  g  i  n  t  o  I  h  e 
m  y  o  m  a  tons  g  r  o  w  t  h  .  The  outer  muscular  covering  looks 
like  normal  muscle.  The  posterior  wall  varies  from  4  to  5  cm.  in 
thickness.  It  is  also  divisible  into  two  layers,  bu1  the  coarse  myo- 
matous arrangement  occupies  nearly  the  entire  wall.  The  uterine 
mucosa  extends  out  for  a  distance  of  fully  2  cm.  and  is  invading 
the  myoma. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — The  epithelium  cov- 
ering the  cervical  mucosa  is  intact  and  the  cervical  glands  are  normal. 
In  the  vicinity  of  the  broad  ligament  are  a  couple  of  glands  lined 
with  cylindrical  epithelium.  They  resemble  uterine  glands  and  are 
surrounded  by  a  small  amount  of  stroma  similar  to  that  of  the 
uterine  mucosa.  The  uterine  mucosa  has  an  intact  surface  epithe- 
lium. Its  "lands  are  very  abundant.  In  its  superficial  portions 
they  are  for  the  most  part  small  and  round;  and  on  cross-section, 
in  the  vicinity  of  the  muscle  considerably  dilated.  In  favorable 
sections  one  can  trace  the  gland,  which  is  narrowed  in  its  upper 
portion,  downward  until  it  becomes  dilated.  The  gland  cavities 
are  either  empty  or  contain  swollen  desquamated  cells  or  blood;  in  a 
few  are  polymorphonuclear  leucocytes.  The  stroma  of  the  mucosa 
is,  on  the  whole,  denser  than  usual.  Scattered  throughout  the 
superficial  portion  of  the  stroma  are  a  few  small  round  cells  and  a 
few  polymorphonuclear  leucocytes.  Here  and  there  the  glands  are 
seen  to  extend  a  short  distance  into  the  muscle.  Where  the  muscle 
is  gathered  up  into  folds  its  surface  is  covered  by  cylindrical 
epithelium.  Here  and  there  i  n  d  i  v  i  d  u  a  1  g  1  a  n  d  s 
are  seen  e  x  t  e n  d  i  n  g  d  o  w  n  i  n  t  o  t  h  e  m  u  s C 1 e  , 
b  ut  at  so  m  e  points  g  1  a  n  d  s  can  be  t  r  a  c  e  d  d  o  w  n 
b  y  d  i  r  e  C  t  cod  t  inuit  y  f  o  r  a  d  i  s  t  a  n  c  e  o  f  2  c  m  . 
T  his    a  p  p  e  a  r  a  n  c  e    is    f  o  u  n  d    to    r  e  p  r  e  sent   n  o  t  h  - 


28  ADENOMYOMA    OF   THE    UTERUS 

ing  more  than  a  dipping  down  of  the  normal 
glands.  They  are  accompanied  by  characteristic  stroma,  and 
many  of  the  glands  are  dilated.  The  epithelium  lining  those  lying- 
in  the  muscle  has  in  many  places  fallen  off  and  is  lying  free  in  the 
cavity  of  the  glands.  It  looks  as  if  the  glands  in  the  deeper  portion 
were  being  forced  out  of  existence  and  in  the  myomatous  portion 
only  fine  remnants  are  visible.  The  stroma  of  the  mucosa,  however, 
in  such  areas  still  persists.  The  thickened  portions  of  the  uterine 
walls  are  composed  of  irregular  bunches  of  non-striped  muscle 
fibres  cut  longitudinally  and  transversely.  They  have  a  rich  blood- 
supply  and  present  the  usual  appearance.  The  large  nodule  situated 
in  the  fundus  is  composed  of  non-striated  muscle  fibres  cut  longi- 
tudinally and  transversely.  In  many  places  this  tissue  has  under- 
gone complete  hyaline  degeneration,  and  at  some  points  this  hyaline 
material  has  completely  melted  away,  leaving  small  cavities. 

Diagnosis  . — Diffuse  myomatous  thickening  of  the  uterine 
walls;  definite  adenomyoma;  general  pelvic  adhesions. 


CHAPTER   II 

CASES  OF  ADENOMYOMA  IN  WHICH  THE  UTERUS  RETAINS  A 
RELATIVELY  NORMAL  CONTOUR     'Continued) 

Gyn.  No.  2706.     Path.  No.  245. 

Multiple  uterine  m  y  0  m  a  t  a  ,  co  m  m  e  n  c  i  n  g 
diffuse  adenomyom  a  .  A  d  e  11  0  m  y  0  m  a  of  the 
left  uterine  horn.  Right  h  y d  r  0  salpinx;  left 
tubo-ovarian    c y  s  t . 

M.  A.,  white,  aged  forty-seven,  married.  Admitted  April  6, 
1894;  discharged  May  12,  1894.  The  patient  has  been  married 
twenty  years.  She  has  had  no  children  and  no  miscarriages.  The 
menses  are  regular,  with  a  free  flow  and  severe  pain  the  first  day. 
Since  marriage  the  flow  has  lasted  twice  as  long,  is  more  profuse, 
and  the  pain  is  more  severe.  Moderate  leucorrhcea  at  times.  For 
over  two  years  she  has  had  pain  in  the  left  ovarian  region,  only 
constant  for  the  past  month.  During  that  time  there  has  been  a 
continuous  hemorrhage  from  the  uterus,  profuse  at  first,  now  less. 

Operation. — Hystero-myomectomy.  Part  of  the  growth 
was  submucous  and  was  removed  through  the  vagina.  After  the 
operation  the  patient  had  persistent  nausea  and  vomiting  until  the 
fourth  day,  when,  after  the  vomiting  of  an  ascaris  lumbricoides, 
14  cm.  long,  the  nausea  and  vomiting  ceased.  The  maximum 
temperature  was  100.5°  F.,  on  the  third  day.  The  patienl  made  a 
satisfactory  recovery . 

P  a  t  h  .  No.  245  . — The  specimen  consists  of  the  uterus,  the 
dilated  tube  from  the  right  side,  and  an  ovarian  cyst,  together  with 
the  left  tube  and  ovary.  The  uterus  is  7  by  9  by  5.5  cm.  It  has 
been  amputated  through  the  cervix.  The  peritoneal  surface  is 
smooth.  On  the  right  side  about  the  middle  oi  the  fundus  is  a 
myomatous  nodule.  1.5  em.  in  diameter.  At  the  junction  of  the 
left  tube  with  the  uterus  is  a  myomatous  nodule  1.5  em.  in  diameter. 

29 


30  ADENOMYOMA    OF    THE    UTERUS 

The  uterine  walls  average  3  cm.  in  thickness.  They  contain  three 
or  four  myomata,  the  largest  2  cm.  in  diameter.  The  uterine 
mucosa  averages  2  mm.  in  thickness. 

Right  side :  The  tube  is  21  cm.  long,  .8  cm.  in  breadth,  and  dilated 
at  the  uterine  end.  After  passing  outward  6  cm.  it  becomes  con- 
voluted and  occluded.  Behind  this  it  forms  a  sac  5  by  6  cm.  This 
somewhat  resembles  a  pipe-bowl.  On  the  surface  are  numerous 
adhesions.  The  ovary  is  4  by  4  by  1  cm.  The  lower  extremity 
is  occupied  by  a  cyst,  2  by  3  cm. 

The  left  side  is  for  the  most  part  occupied  by  a  cyst,  13  by  12  by 
11  cm.  It  is  smooth  and  glistening  and  traversed  by  numerous 
small  vessels.  Posteriorly  there  are  many  adhesions  and  a  distinct 
sensation  of  fluctuation  is  perceptible.  The  tube  is  17  cm.  long, 
1.5  cm.  broad.  After  passing  outward  6  cm.  it  spreads  over  the 
surface  of  the  tumor  and  finally  merges  into  the  tumor  itself.  The 
ovary  is  5  by  3  by  1  cm. 

Histological  Examination  . — The  cervical  glands 
are  normal.  In  the  body  of  the  uterus  the  mucosa  is  somewhat 
edematous.  Some  of  the  glands  run  parallel  with,  instead  of  at 
right  angles  to,  the  underlying  muscle.  As  one  approaches  the 
fundus  the  mucosa  reaches  5  mm.  in  thickness.  The  glands  are  very 
long.  Their  epithelium  is  intact.  Some  of  the  glands 
have  extended  down  into  the  muscular  layer. 
The  stroma  in  places  is  infiltrated  with  small  round  cells,  and  in 
the  deeper  portions  of  the  mucosa  are  a  few  lymphoid  cells.  The 
blood-vessels  of  the  mucosa  appear  to  be  more  numerous  than 
usual  and  in  places  are  dilated. 

The  right  cornu  is  normal.  The  left  contains  numerous  cyst- 
like spaces,  some  of  them  situated  on  the  side  of  the  tube,  others 
lying  2  to  4  mm.  beneath  the  peritoneal  surface.  These  glands 
are  small  and  round  or  are  irregular  and  dilated.  They  are  lined 
with  one  layer  of  cylindrical  epithelium,  which  in  some  places  rises 
directly  from  the  muscle.  In  other  places  it  is  surrounded  by  a 
faint  amount  of  stroma  similar  to  that  of  the  uterine  mucosa.  The 
glands    are    dilated.     The    muscular    tissue    around    these    glands 


DIFFUSE    ADENOMYOMA    OF   THE    UTERI  -  31 

presents  a   distinct    myomatous   appearance.     One   of   the  glands 
contains  a   little  finger-like  ingrowth. 

Diagnosis.  Multiple  uterine  myomata.  Commencing  dif- 
fuse adenomyoma;  adenomyoma  of  the  left  uterine  horn;  right 
hydrosalpinx;  left  tubo-ovarian  cyst. 

Gyn.  No.  3809.     Path.  No.  881. 

Discrete  s  u  b  p  e  r  i  t  o  n  e  a  1  and  interstitial 
uterine  m  y  0  in  a  t  a  .  Co  m  m  e  n  c  i  n  g  d  i  f  f  u  s  e  a  d  e  n  o  - 
in  y  o  m  a  t  o  u  s  for  m  a  t  i  o  11  w  i  t  li  t  h  e  g  1  a  n  d  s  o  r  i  g  - 
i  n  a  1  i  n  g  f  r  o  m  the  mucosa.  General  pelvic  ad- 
hesions, probable  remains  of  the  Wolffian 
b  o  d  y    in    the    left    o  v  a  r  y. 

S.  F.,  aged  thirty-six,  white.  Admitted  September  21,  1895; 
discharged  October  19,  1895.  The  last  period  appeared  two  weeks 
ago;  the  flow  was  somewhat  free  and  there  was  much  pain.  The 
bowels  are  constipated,  defecation  is  painful.  Micturition  is  scant 
and  painful  and  at  times  it  is  necessary  to  catheterize. 

0  p  e  r  a  t  i  o  n  . — Hystero-salpingo-oophorectomy.  Considerable 
difficulty  was  experienced  owing  to  the  omental  adhesions  to 
the  abdominal  wall.  The  uterus  was  everywhere  adherent.  It  was 
removed  entirely.  The  highest  temperature  was  lnn.fr  I\.  four 
days  after  the  operation.  The  patient  made  an  uninterrupted 
recovery. 

Path.  No.  8  8  1  . — The  specimen  consists  of  the  uterus  with 
the  appendages  intact.  The  uterus  is  7  by  6.5  by  6.5  cm.;  it  is 
covered  by  dense  adhesions.  On  the  posterior  surface  are  two  flat 
pedunculated  nodules,  l.S  cm.  in  diameter.  These  are  covered  by 
adhesions.  The  uterine  cavity  is  4.5  cm.  in  length  and  4  cm.  in 
breadth.  At  the  fundus  the  mucosa  presents  a  slightly  roughened, 
granular  appearance,  and  projecting  into  the  cavity  from  the  lower 
third  of  the  posterior  wall  is  a  myomatous  nodule.  .">  by  3  cm.  The 
uterine  mucosa  averages  1  mm.  or  more  in  thickness.  The  uterine 
muscle  averages  2.5  cm.  in  thickness.  It  contains  several  firm 
nodules  averaging  1  cm.  in  diameter.     On  the  right  side  the  tube 


32  ADEXOMYOMA    OF   THE    UTERUS 

is  5.5  cm.  in  length  and  varies  from  5  to  8  mm.  in  thickness.  Its 
surface  is  covered  by  a  few  adhesions  and  it  contains  a  cyst  1.5  cm. 
in  diameter,  near  the  fimbriated  end.  The  fimbriated  extremity 
is  patent  and  measures  .8  cm.  in  diameter.  It  is  also  covered 
by  adhesions.  On  pressure  pus  exudes  from  the  fimbriated 
extremity.  The  ovary  is  normal  in  size,  much  mutilated,  and 
covered  by  adhesions. 

Histological  Examination  . — The  uterine  mucosa 
has  not  been  well  preserved.  The  glands,  where  present,  are  normal 
and  have  an  intact  epithelium.  The  stroma  of  the  mucosa  shows 
a  moderate  amount  of  small  round-cell  infiltration  and  the  uterine 
glands  exhibit  a  peculiar  tendency  to  extend 
a  short  distance  into  the  muscle.  Most  of  these 
are  surrounded  by  normal  stroma,  but  a  few  lie  in  direct  continuity 
with  the  muscle.  Sections  through  the  nodules  present  a  typical 
myomatous  appearance. 

Right  side:  The  tube  presents  the  usual  appearance,  but  the 
tube  lumen  contains  a  moderate  amount  of  blood.  Sections  through 
the  left  cornu  show  that  the  epithelium  in  places  is  slightly  swollen 
and  that  it  has  here  and  there  cyst-like  spaces  which  contain  a  few 
polymorphonuclear  leucocytes  and  apparently  some  desquamated 
epithelial  cells.  Situated  apparently  in  the  hilum  of  the  left  ovary 
is  an  irregular,  deeply  staining  area  composed  of  irregular  spindle- 
shaped  cells  which  suggest  connective  tissue ;  and  scattered  through 
this  tissue  are  irregular  gland-like  spaces,  each  of  which  is  lined  with 
one  layer  of  cylindrical  epithelium.  The  spindle-shaped  cells  are 
arranged  in  layers  around  the  gland-like  spaces.  They  are  probably 
remains  of  the  Wolffian  body. 

In  further  sections  through  the  adhesions  on  the  posterior  surface 
of  the  uterus,  the  uterine  muscle  just  beneath  the  mucosa  is  seen  to 
contain  in  some  places  one,  in  others  three  or  four  gland-like  spaces. 
These  are,  however,  slit-like  in  contour.  They  are  lined  with  one 
layer  of  cylindrical  epithelium  in  which  cilia  are  in  many  places 
visible.  These  cavities  are  either  empty  or  contain  granular  de- 
tritus, and  here  and  there  some  desquamated  epithelium.     Some  of 


DIFFUSE    ADENOMYOMA    OF   THE    UTERUS  33 

the  glands  lie  in  direct  contact  with  the  muscle.  Others  have  a 
definite  stroma  surrounding  them.  This  stroma  is  similar  to  thai 
of  the  uterine  mucosa.  Around  one  of  the  glands  the  muscle  is 
arranged  in  a  circular  manner.  It  looks  as  if  it  were  forming  a 
definite  coat. 

D  i  a  g  n  o  s  i  s  . — General  pelvic  adhesions.  I  Mscrete  sub- 
peritoneal and  interstitial  nryomata.  Commencing  diffuse  adeno- 
myoma;  probable  remains  of  the  Wolffian  body  in  the  left  ovary. 

Gyn.  No.  9069.     Path.  No.  5229. 

C  o  m  m  e  n  c  i  n  g  diffuse  a  d  e  n  o  m  y  0  m  a  of  the 
uterus;    slight    pelvic    peritonitis. 

M.  M.,  aged  thirty-five,  white,  married.  Admitted  September  17, 
1901;  discharged  October  2,  1901.  Father,  brother,  and  grand- 
father died  of  pulmonary  tuberculosis.  The  patient  has  always 
been  rather  delicate  and  has  had  pneumonia  three  times.  Her 
menses  began  at  twelve,  were  regular,  lasting  two  or  three  days; 
the  flow  was  scant  and  painful.  She  has  had  a  leueorrhoeal  discharge 
since  childhood.  In  1897  the  uterus  was  suspended.  In  1899  she 
returned  with  a  retroversion.  This  time  she  complained  of  more 
severe  pain  than  she  had  had  before  the  suspension  was  done.  The 
most  prominent  symptoms  were  backache  and  frequency  of  urina- 
tion.    There  is  no  history  of  any  severe  hemorrhage. 

Operation  . — Hystero-salpingo-oophorectomy.  The  patient 
made  an  uninterrupted  recovery. 

Path.  X  o  .  5229  . — The  specimen  consists  of  the  uterus, 
tubes,  and  ovaries.  The  uterus,  including  the  cervix,  is  5.5  by  4.5 
by  2.5  cm.  Its  peritoneum  is  smooth  and  glistening.  At  the  fundus 
is  a  tag  of  tissue  the  result  of  the  suspension  of  two  years  ago.  The 
cervical  canal  appears  as  a  transverse  slit  5  mm.  broad.  The  muc<  >sa 
is  exceedingly  thin  in  the  upper  part  of  the  cavity;  it  is  granular 
and  much  congested.  The  appendages  on  both  sides  are  covered 
with  adhesions. 

The  cervical  mucosa  is  normal.     Many  of  the  glands,  however, 

are  much  dilated. 
3 


34  ADENOMYOMA    OF    THE    UTERUS 

Sections  from  the  endometrium  show  the  mucosa  in  places  to 
be  very  ragged,  possibly  the  result  of  curettage.  In  other  places 
the  surface  epithelium  is  intact.  The  stroma  is  slightly  edematous. 
At  some  points  the  underlying  muscle  shows 
a  distinct  myomatous  tendency  and  we  have 
a  direct  extension  of  the  glands  into  the  un- 
derlying tissue,  the  picture  presented  being  typical  of 
adenomyoma. 

Diagnosis  . — Pelvic  peritonitis ;  commencing  adenomyoma ; 
small  cyst  of  the  ovary. 

Gyn.  No.  7153.     Path.  No.  3429. 

Diffuse  adenomyoma  occupying  the  an- 
terior, posterior,  and  lateral  uterine  walls; 
in  short,  forming  a  mantle  around  the  uterine 
cavity  (Figs.  5,  6,  7).  Slight  pelvic  peritonitis. 
Hysterectomy.     Recovery. 

S.  W.,  aged  fifty-six,  white,  married.  Admitted  August  24, 
1899;  discharged  September  26,  1899.  Complaint:  pelvic  tumor 
and  hemorrhages  from  the  uterus.  The  patient  has  been  married 
thirty-four  years,  has  had  thirteen  children;  the  youngest  is  thir- 
teen years  of  age.  She  has  had  one  miscarriage.  The  menses 
commenced  at  thirteen,  were  regular,  and  lasted  a  week.  For  the 
last  ten  years  they  have  been  very  profuse.  Sometimes  recently 
she  would  lose  as  much  as  a  quart  of  blood. 

There  has  been  a  slight  leucorrhceal  discharge.  The  patient  is 
very  anaemic  and  presents  a  blanched  appearance.  She  has  a 
slightly  intermittent  pulse.  The  outlet  is  markedly  relaxed  and 
the  vaginal  walls  are  redundant.  The  cervix  is  in  the  axis  of  the 
vagina  and  points  slightly  to  the  right.  It  is  about  four  or  five 
times  the  normal  size.  The  cervical  lips  are  thin  and  rigid.  The 
uterus  is  somewhat  enlarged  and  irregular  in  outline.  The  lateral 
structures  cannot  be  palpated. 

Operation  August  28,  1899.  —  Hystero-salpingo- 
oophorectomy.     The  patient  made  a  satisfactory  recovery. 


DIFFUSE    ADENOMYOM  V    OF   THE    I  TER1  - 


35 


Gyn.-Path.  No.  3  429.  The  specimen  consists  of 
the  uterus  with  the  appendages  intact.  The  uterus  is  slightly 
enlarged.  It  has  been  amputated  a1  the  cervix.  The  body  is  6 
cm.  in   length,  6  cm.  in 

breadth,  and  4.5  cm.  in 
its  anteroposterior  di- 
ameter. The  outer  sur- 
face is  covered  with  ad- 
hesions. These  are  especi- 
ally abundant  over  the 
fundus  and  posterior  sur- 
face of  the  uterus.  Both 
the  a  n t  e  r  i  o r  a  n d 
posterior  walls 
average  2.5  c  m . 
in  thickness  a n  d 
a  r  e  r  e  a  d  i  1  y  di- 
visible into  two 
zones.  The  inner 
consists  of  dense 
muscular  tissue; 
the  fibres  run  in 
and  out  in  all  di- 
rections an d  for  m 
definite  whorls 
(Fig.  5).  Situated  in 
this  diffuse  growth  are 
also  a  few  small  circum- 
scribed myomata.  The 
coarse  myomatous  tissue 
extends  directly  to  the  mucosa,  but  apparently  does  not  encroach 
upon  it.  At  one  or  two  points  brownish  areas,  rather  porous  in 
appearance  and  faintly  resembling  uterine  mucosa,  are  found  in  the 
myomatous  tissue  some  distance  from  the  mucosa.  The  outer 
portion  of  the  uterine  wall  consists  of  normal  muscle.     This  forms  a 


Fig.    5. — Diffuse   adenomyoma    forming   a   complete 

ZONE  AROl'XD  THE  UTERINE  CAVITY.       i  Natural  size.) 

G  y  n  .  No.  3429.  The  figure  represents  an 
anteroposterior  section  through  the  entire  uterus  which 
has  been  amputated  through  the  cervix.  The  uterine 
cavity  is  of  the  normal  length  and  appearance  and  the 
mucosa  is  probably  thinner  than  usual.  The  inner  two- 
thirds  of  the  muscular  wall  have  been  completely  trans- 
formed into  a  diffuse  myomatous  tissue  which  extends  to, 
hut  dues  not  encroach  upon,  the  uterine  cavity.  At  a 
is  a  small  cyst  with  a  smooth  inner  lining.  The  outer 
portion  of  the  uterine  wall  consists  of  perfectly  normal 
muscle.  Scattered  throughout  it  are  many  cross-sections 
of  small  blood-vessels,  well  shown  at  /».  Although  the 
myomatous  muscle  sharply  contrasts  with  the  normal 
muscle,   the   two   gradually   merge   into   one   another   and 

are  intimately  blended.     For  the  histological  appearance 
see  Figs.  <>  and  7. 


36  ADENOMYOMA   OF  THE    UTERUS 

covering  varying  from  3  to  5  mm.  in  thickness  and  is  sharply  dif- 
ferentiated from  the  diffuse  myoma.  The  uterine  cavity  is  5  cm. 
in  length  and  at  the  fundus  4  cm.  broad.  The  mucosa  is  perfectly 
smooth  and  is  apparently  not  over  1  mm.  in  thickness.  Just  within 
the  internal  os,  however,  is  a  polypoid  outgrowth,  1.2  by  .6  by  .4  cm. 

Right  side:  The  tube  is  10  cm.  long  and  varies  from  4  to  11  mm. 
in  diameter.  It  is  covered  with  vascular  adhesions  and  its  fimbriated 
extremity  is  occluded  and  adherent  to  the  ovary.  The  ovary  is 
senile  in  character;  it  measures  2.5  by  1.8  by  1.5  cm.  and  is  covered 
with  adhesions. 

Left  side:  The  tube  is  10  cm.  in  length  and  5  mm.  in  diameter. 
Its  fimbriated  extremity  is  patent,  but  the  fimbriae  have  here  and 
there  become  agglutinated;  the  ovary  is  senile;  it  measures  3  by 
1.8  by  1.3  cm. 

Histological  Examination  . — Sections  through  the 
polyp  near  the  internal  os  show  that  it  is  composed  almost 
entirely  of  cervical  tissue.  The  glands  are  abundant,  and  apart 
from  being  dilated  offer  little  of  interest.  The  mucosa  lining  the 
uterine  cavity  has  for  the  most  part  an  intact  surface  epithelium. 
This  epithelium  is  low  cylindrical  in  type.  The  uterine  glands 
present  the  usual  appearance  and  are  lined  with  one  layer  of  cylindri- 
cal epithelium.  At  numerous  points  the  mucous  membrane  ex- 
tends directly  into  the  underlying  myomatous  tissue  (Figs.  6  and  7). 
Sometimes  it  is  possible  to  trace  it  for  a  distance  of  6  or  7  mm. 
The  extension  into  the  muscle  varies  in  different  places.  At  some 
points  prolongations  4  or  5  mm.  broad  extend  from  the  mucosa  into 
the  depth.  At  other  points  a  large  area  of  mucosa  in  the  depth  will 
communicate  with  the  surface  by  an  actual  isthmus.  The  thickening 
of  the  anterior  and  posterior  uterine  walls  is  due  to  the  presence  of 
myomatous  tissue.  As  was  noted  macroscopically,  this  forms  a 
broad  zone  between  the  mucosa  and  the  outer  covering  of  normal 
muscle.  The  fibres  of  this  myomatous  tissue  are  particularly  well 
preserved  and  wind  in  and  out  in  all  directions.  Scattered 
everywhere  throughout  the  myomatous  zone 
are     islands     of     mucous     membrane     identical 


DIFFUSE    ADENOMYOMA    OF   THE    UTERI  S 


37 


! 


'"V 


1 


*«& 


^ 


i 


f 


~-**Vjv*.-'' 


Fig.  6. — Diffuse   adeno.myo.ma  of   the    uterine  wall    with   marked    extension    of   the 
mucosa  into  the  growth.     (4  diameters.) 

Gyn.-Path.  No.  3429.  This  is  a  section  through  the  entire  uterine  wall  in  Fig.  5. 
a  indicates  the  uterine  mucosa;  b,  the  outer  covering  of  normal  muscle.  The  intervening  portion, 
comprising  the  major  part  of  the  uterine  wall,  consists  of  diffuse  myomatous  tissue.  The  uterine 
mucosa  at  a  is  of  the  normal  thickness  and  presents  the  usual  appearance.  It  i-  immediately 
noticeable  that  the  surface  is  perfectly  even,  there  being  no  tendency  toward  the  formation  of 
outgrowths.  At  C  there  is  a  wholesale  extension  of  mucosa  into  the  diffuse  myoma.  At  &  and 
c"  the  mucosa  can  be  traced  for  a  considerable  distance,  but  at  <■'"  a  most  instructive  picture  is 
seen.  Here  we  are  able  to  follow  the  extension  of  the  mucosa  fully  two-thirds  of  the  way  through 
the  uterine  wall  and  almost  to  the  point  where  the  diffuse  growth  end-  and  the  normal  muscle 
begins.  It  will  be  noted  that  the  usual  stroma  accompanies  the  glands.  At  numerous  other 
points,  indicated  by*/,  the  mucosa  is  seen  penetrating  the  myoma.  Scattered  throughout  the 
diffuse  growth  are  many  islands  of  uterine  mucosa  containing  anywhere  from  one  to  a  dozen  or 
more  sections  of  glands  embedded  in  the  characteristic  stroma.  A  few  of  the  glands  are  dilated 
as  shown  at  c.  Here  and  there  there  are  islands  of  stroma  (/)  devoid  of  glands.  The  glandular 
invasion  in  this  case  is  remarkable,  but  it  will  lie  noted  thai  DO  epithelial  elements  are  found  in  the 
normal  muscle. 


38 


ADENOMYOMA   OF   THE    UTERUS 


with  that  lining  the  uterine  cavity.  Some  of 
these  are  not  more  than  1  mm.  in  diameter;  others  much  larger. 
Frequently  they  are  cut  lengthwise  and  can  be  traced  for  a  distance 


*%&  ^* 


c  c 

Fig.  7. — Extension  of  the  mucosa  into  a  diffuse  myoma  of  the  uterus.     (12  diameters.) 

Gyn.-Path.  No.  3429.  The  section  is  from  the  body  of  the  uterus  represented 
in  Fig.  5.  A  very  low-power  picture  of  this  is  seen  in  Fig.  6.  a  represents  the  thickness  of  the 
normal  mucosa.  The  surface  epithelium  is  intact  and  the  surface  of  the  mucosa  is  comparatively 
smooth.  At  b  we  have  an  angle  where  the  lateral  wall  joins  the  top  of  the  uterine  cavity.  The 
greater  number  of  the  uterine  glands  are  normal  in  size,  but  a  few  are  dilated.  The  normal 
mucosa  is  everywhere  extending  into  the  diffuse  myoma,  as  indicated  by  c.  The  mucosa  in  the 
down-growths  differs  in  no  way  from  that  lining  the  uterine  cavity  save  for  the  fact  that  some  of 
the  glands,  as  seen  at  d,  are  dilated.  This  is  another  example  of  what  we  have  many  times 
reiterated,  namely,  that  the  mere  extension  of  uterine  glands  into  the  muscle  is  not  necessarily 
indicative  of  a  malignant  growth. 


of  at  least  1  cm.  and,  as  was  said  before,  near  the  mucosa  t  h  e  i  r 
direct  connection  with  the  mucous  membrane 
is    established.      The  glands  forming  these  islands  can  in 


DIFFUSE    A.DENOMYOMA    OF   THE    I  TER1  -  39 

no  way  be  differentiated  from  those  of  the  mucous  membrane. 
They  are  similar  in  shape  and  are  lined  with  one  layer  of  the  char- 
acteristic cylindrical  ciliated  epithelium.  Surrounding  ili<--<-  glands 
is  the  typical  si roma  of  the  mucosa.  Some  of  the  glands  are  dilated, 
and  at  least  three  or  four  of  them  reach  a  diameter  of  2  nun.  The 
epithelium  of  the  dilated  glands  is  somewhat  flattened,  stains  palely, 
and  the  gland  cavities  contain  desquamated  epithelium.  In  one 
of  the  cavities  two  ill-defined  gianl  cells  are  present,  produced 
apparently  by  a  coalescence  of  desquamated  epithelium.  Not 
infrequently  are  seen  little  islands  of  stroma  staining  deeply  and 
having  the  characteristics  of  that  of  the  uterine  mucosa,  lying  in 
between  muscle  bundles.  The  outer  covering  of  uterine  muscle  is 
perfectly  normal. 

In  this  case  it  is  possible  to  trace  a  definite  relation  between  the 
islands  of  the  mucosa  and  myomatous  muscle.  AVhere  the  mucosa 
is  seen  extending  into  the  depth  the  myomatous  fibres  run  parallel 
with  the  penetrating  mucosa.  Where  this  penetrating  mucous 
membrane  is  cut  transversely,  we  accordingly  find  the  islands  of 
mucous  membrane  surrounded  by  bundles  of  myomatous  tissue 
also  cut  transversely.  External  to  this  zone  we  usually  find  a 
second  in  which  the  fibres  run  at  right  angles  to  the  projection. 

This  case  is  certainly  a  most  interesting  one.  We  have  a  fairly 
large  uterine  cavity  and  the  inner  two-thirds  of  the  anterior,  pos- 
terior and  lateral  walls  are  replaced  by  a  diffuse  myomatous  growth. 
The  underlying  layers  of  the  mucosa  have  penetrated  this  diffuse 
myoma  in  all  directions,  exactly  in  the  same  manner  as  roots  enter 
the  soil.  Accordingly,  at  favorable  points  where  we  have  obtained 
longitudinal  sections  we  are  able  to  trace  a  direct  extension  into  the 
depth.  At  many  points,  however,  these  rootlets  in  the  depth  have 
been  cut  transversely,  and  are  then  recognized  as  isolated  islands  of 
mucous  membrane  surrounded  by  myomatous  tissue.  Where  the 
diffuse  myoma  ends,  this  extension  of  the  mucosa  into  the  depth 
ceases  and  the  entire  myoma  is  covered  with  a  layer  of  normal 
uterine  muscle.  This  growth  is  without  a  doubt  benign  in  character. 
The  appendages  offer  nothing  of  interest. 


40  ADENOMYOMA   OF   THE    UTERUS 

Diagnosis  . — Diffuse  adenomyoma  occupying  the  anterior, 
posterior,  and  lateral  uterine  walls;  slight  pelvic  peritonitis. 

Path.  No.  8760. 

Diffuse  adenomyoma  of  the  body  of  the 
uterus  with  the  glands  originating  from  the 
uterine    mucosa. 

A.  H.  Operated  upon  at  the  Church  Home  on  June  9,  1905. 
Operation:  complete  hysterectomy.  The  specimen  consists  of  the 
entire  uterus  with  the  tubes  and  ovaries  attached,  and  there  is  also 
a  portion  of  the  vaginal  mucosa.  The  uterus  measures  9  by  5  by 
4  cm.  Its  anterior  surface  is  normal;  its  posterior  slightly  irregular, 
owing  to  the  presence  of  two  small  myomatous  nodules  averaging 
1  cm.  in  diameter.  These  project  a  few  millimetres  from  the  surface. 
The  uterine  walls  vary  from  1.5  to  2.5  cm.  in  thickness.  The 
uterine  mucosa  appears  normal  except  for  the  presence  of  a  polyp, 
which  for  .3  cm.  projects  into  the  cavity  from  the  posterior  wall. 

Right  side:  The  tube  contains  two  ostia.  The  right  ovary  con- 
tains a  small  cyst.     The  left  appendages  are  normal. 

Histological  Examination  . — Sections  from  the 
uterine  mucosa  show  an  intact  surface  epithelium.  Many  of  the 
glands  are  dilated  and  the  stroma  generally  appears  normal.  I  n 
numerous  places  the  glands  with  their  ac- 
companying stroma  can  be  traced  directly 
into  the  muscular  tissue.  The  muscle  shows  diffuse 
myomatous  transformation.  Some  of  the  glands  in  the  myomatous 
areas  are  markedly  dilated.  Isolated  gland  spaces  are  found  scat- 
tered throughout  the  diffuse  myomatous  tissue,  but  none  are  visible 
in  the  neighborhood  of  the  peritoneal  surface. 

Diagnosis  . — Diffuse  adenomyoma  of  the  body  of  the 
uterus;    normal   tubes   and   ovaries. 

H.  A.  K.  Sanitarium  No.  2144.     Path.  No.  9705. 
Diffuse    adenomyoma    involving    the    entire 
body  of  the  uterus  with  the  glands  distinctly 


DIFFUSE    ADENOMYOM  \    OF   THE    UTERI  -  11 

r  i  s  i  11  g  I'  r  o  m  I  li  e  m  u  c  o  s  n  :  s  1  i  g  li  I  e  n  d  o  in  <•  I  r  i  I  i  a  : 
(1  i  s  c  r  etc     L  n  t  e  r  S  t  i  1  i  ;i  1     in  y  0  in  ;i  1  a  . 

V.  M.  R.,  white,  aged  thirty-nine,  married.  Admitted  April  6, 
L906;    discharged  May  22,  L906.     The  patienl  has  had  do  children, 

no  miscarriages.  She  entered  complaining  of  dysmenorrhea,  free 
uterine  hemorrhage,  and  some  leucorrhcea.  Ob  admission  her 
haemoglobin   was   70   per  cent. 

O  p  e  r  a  t  i  o  n  . —  Hystero-myomectomy.  The  patienl  made  an 
uneventful  recovery.  Her  highest  post-operative  temperature  was 
101.6°  F.,  twenty-four  hours  after  operation. 

Path.  X  o  .  9705  . — The  specimen  consists  of  the  uterus, 
considerably  enlarged,  which  has  been  amputated  through  the  cervix. 
It  is  10  cm.  in  length,  10  cm.  in  breadth,  and  17  cm.  in  its  antero- 
posterior diameter.  Situated  in  the  anterior  wall  is  a  myoma  3  cm. 
in  diameter.  The  posterior  wall  varies  from  2.5  to  4.5  cm.  in  thick- 
ness; the  anterior  wall  from  2  to  2.5  cm.  The  increase  in  thickness 
is  due  to  a  diffuse  myomatous  transformation  of  the  posterior  wall, 
which  is  also  present  in  the  anterior  wall. 

Sections  from  the  endometrium  show  that  the  surface  epithelium 
is  intact.  The  mucosa  in  the  superficial  portion  shows  typical 
gland  hypertrophy  and  there  is  a  great  deal  of  small  round-cell 
and  polymorphonuclear  cell  infiltration,  giving  a  picture  of  subacute 
endometritis.  The  mucosa  in  the  deeper  layers  is  perfectly  normal 
and  can  be  followed  directly  into  the  myomatous  tissue.  Scat- 
tered t  h  r  o  u  g  h  o  u  t  the  a  n  t  e  r  i  o  r  a  n  d  p  o  s  t  e  r  i  o  r 
walls  every  w  here  are  1  a  r  g  e  a  n  d  small  islands 
of  uterine  mucosa.  The  glands  are  normal.  The  diffuse 
myomatous  tissue  is  everywhere  riddled  with  islands  of  mucosa, 
some  of  them  2  mm.  in  length,  and  in  one  section  it  is  sometimes 
possible  to  make  out  thirty  or  more  islands  of  mucosa  scattered 
throughout   the  myoma. 

Diagnosis. — Diffuse  adenomyoma  involving  the  entire 
body  of  the  uterus  with  the  glands  distinctly  arising  from  the  mucosa  ; 
slight  endometritis.     Discrete  interstitial  myomata. 


42 


ADENOMYOMA   OF   THE    UTERUS 


Gyn.  No.  2754.     Path.  No 
Diffuse     a  d  e  n  o  m  y  o  m  a     of     t 


Fig.  8. — Diffuse  adenomyoma  of  the  anterior  uterine 
wall.     (Natural  size.) 

Gyn. -Path.  No.  290.  This  is  an  antero-pos- 
terior  section  of  the  uterus.  The  organ  has  been  amputated 
through  the  cervix.  The  anterior  lip  of  the  cervix  is  consider- 
ably thickened.  The  anterior  uterine  wall  is  increased  in  thick- 
ness. It  is  covered  externally  with  a  zone  of  normal  mus- 
cle, but  the  major  portion  of  the  thickening  is  composed  of 
a  diffuse  myomatous  growth  which  has  encroached  to  a  marked 
degree  on  the  uterine  cavity.  In  this  diffuse  myoma  several 
small  discrete  myomata  are  visible.  A  few  of  the  cervical 
glands  are  dilated  and  lying  in  the  cervical  canal  is  a  polyp. 
The  uterine  cavity  is  considerably  lengthened.  The  mucosa  of 
the  anterior  wall  is  of  the  usual  thickness,  but  at  numerous 
points  it  can  be  seen  penetrating  the  diffuse  myoma  for  a  short 
distance.  The  posterior  wall  is  relatively  normal,  but  at  a 
contains  a  submucous  myoma.  Attached  to  the  uterus 
is  the  proximal  end  of  the  right  tube.  For  the  histological 
picture  of  the  diffuse  growth  in  the  anterior  wall  see  Figs. 
9  and  10. 


290. 

he  uterine  wall 
(Figs.  8,  9,  and  10). 
Hysterectomy  ; 
Recovery. 

R.M.,  married,  aged 
fifty-four.  Admitted 
May  2,  discharged  June 
5,  1894.  The  menses 
commenced  at  eigh- 
teen, were  regular,  pro- 
fuse but  painless.  Five 
months  ago  the  men- 
strual flow  became  pro- 
fuse and  lasted  much 
longer,  with  flooding 
each  month. 

The  patient  has 
been  married  thirty- 
two  years  and  has  had 
ten  children  and  one 
miscarriage.  After  the 
third  labor  there  was 
puerperal  fever.  At 
present  she  complains 
of  a  dull  aching  pain  in 
the  right  lower  abdo- 
men. On  examination 
the  left  side  of  the  pel- 
vis is  found  filled  with 
a  mass  which  cannot 
be  differentiated  from 
the  uterus.  It  is  firm, 
sensitive,  and  immo- 
bile. 


DIFFUSE    A.DENOMYOMA    OF   THE    UTERUS 


43 


Operation.      Vaginal    hystero-myomectomy.     Double    sal- 
pingo-oophorectomy.     The   base   of   the   bladder   was   opened    for 


a-- 


c       b 
Fig.  9. — Diffuse  adenomyoma  of  the  anterior  uterine  wall.     r_'\  diameters. 

G  y  n  .  -  P  a  t  h  .  No.  290.  This  is  a  section  through  the  anterior  uterine  wall  in  Fig. 
8.  Almost  the  entire  wall  consists  of  diffuse  myomatous  tissue,  but  at  the  points  indicated  by  " 
three  discrete  nodules  are  visible,  and  between  these  and  the  mucosa  is  a  fourth  one.  h  represents 
the  usual  thickness  of  the  mucosa,  and  it  will  be  seen  that  it  is  normal.  In  many  places,  a-  indi- 
cated by  c.  the  mucosa  is  seen  extending  into  the  myoma  and  there  sending  off  numerous  secondary 
branches.  At  <l  is  an  island  of  mucosa  situated  deep  in  the  muscle,  but  showing  at  several  points 
continuity  with  the  mucosa  lining  the  uterine  cavity.  Scattered  throughout  the  inner  half  of 
the  uterine  walls  are  glands  occurring  in  bunches  or  singly.  They  arc  invariably  surrounded  by 
dark  zones  which  represent  normal  stroma  of  the  mucosa.  The  glands  can  be  traced  as  far  out- 
ward as  e.  /  represents  a  tear  in  the  specimen.  It  is  clear  that  the  glands  in  this  diffuse  adeno- 
myoma have  originated  from  the  uterine  mucosa. 


4  cm.  during  the  operation.  It  was  sutured.  After  the  operation 
the  patient  complained  of  pain  in  the  bladder  for  several  days  and 
passed  some  pns. 

i  i  y  n  .  -  P  a  t  h  .    No.    2  9  0  . — The  specimen    consists  of   the 


44 


ADENOMYOMA   OF   THE    UTERUS 


;>_4§b^ 

,,- 

i 

.'.. 

- 

U.B*cKe&yj>. 

-d. 


Fig.    10. — Mode    of   extension  of  uterine 


GLANDS     INTO     A 

(10  diameters.) 
Gy  n  .-Path. 


DIFFUSE     ADENOMYOMA. 


No.  290.  The  sec- 
tion is  from  the  diffuse  adenomyoma  in  the  an- 
terior wall  of  the  uterus  in  Fig.  8.  a  is  a  por- 
tion of  the  normal  uterine  mucosa.  The  super- 
ficial layers  have  accidentally  been  removed  by 
mechanical  injury.  The  mucosa  can  be  traced 
by  direct  continuity  to  a'.  It  will  be  seen  that 
the  glands,  apart  from  some  dilatation,  are  per- 
fectly normal,  and  that  they  are  accompanied 
by  the  stroma  of  the  mucosa,  b  is  an  island 
of  stroma  containing  one  uterine  gland.  This 
stroma  can  be  traced  upward  nearly  to  the  sur- 
face, downward  as  far  as  c.  The  irregularity  in 
its  course  is  undoubtedly  due  to  the  unequal 
pressure  of  the  ever-growing  diffuse  myoma. 
d  is  an  island  of  stroma  devoid  of  glands;  e,  an- 
other point  where  the  mucosa  is  penetrating 
the  myoma. 


uterus,  tubes,  and  ovaries  intact. 
The  uterus  is  12  cm.  long,  7  cm. 
broad,  and  6.5  cm.  in  the  antero- 
posterior diameter.  Both  ante- 
riorly and  posteriorly  it  is  smooth 
and  glistening.  The  cervix  is  4 
cm.  in  diameter.  The  posterior 
uterine  wall  is  about  2.5  cm.  in 
thickness  and  somewhat  striated. 
It  contains  a  submucous  myoma, 
2.5  cm.  in  diameter.  The  an- 
terior wall  near  the  cervix  is  2 
cm.  in  thickness,  but  rapidly  be- 
comes thicker  and  forms  a  diffuse 
growth  3.5  cm.  thick  (Fig.  8). 
This  encroaches  to  a  consider- 
able extent  on  the  uterine  cavity. 
It  presents  a  very  coarse  striation 
resembling  a  diffuse  myoma,  and 
scattered  throughout  it  are  sev- 
eral well-defined  myoma ta,  vary- 
ing from  2  to  6  mm.  in  diameter. 
The  cervical  mucosa  presents  the 
usual  appearance.  The  uterine 
cavity  is  6.5  cm.  long  and  its 
mucosa,  which  is  intact,  is  ap- 
parently 1  mm.  in  thickness. 

Right  side:  The  tube  is 
normal  in  size  but  covered  by 
numerous  adhesions.  The  ovary 
is  unaltered. 

Left  side :  The  tube  and  ovary 
seem  to  be  normal. 

Histological  Exam- 
i  n  a  t  i  o  n  . — The  cervical  glands 


DIFFUSE    A.DEN0MY0MA    OF   THE    CJTER1  -  1") 

are  normal.  The  uterine  mucosa  is  about  1  mm.  in  thickness; 
its  surface  epithelium  is  intact,  but  is  low  cylindrical  or  cuboidal 
in  character.  The  glands  are  few  in  number  and  are  here  and  there 
slightly  dilated.  The  gland  epithelium  is  low  cylindrical  in  type 
and  is  intact.  The  stroma  of  the  mucosa  is  somewhat  lax  and  is 
made  up  of  cells  having  elongated  or  oval  nuclei  which  are  separated 
from  each  other  by  red  corpuscles  and  large  vacuolated  spaces.  In 
other  words,  the  tissue  of  the  stroma  is  edematous,  more  especially 
in  the  superficial  portions.  The  diffuse  thickening  in  the  posterior 
wall  is  due  to  a  myomatous  transformation  of  the  uterine  muscle, 
with  here  and  there  the  development  of  young  circumscribed  myo- 
mata.  Where  the  diffuse  myoma  is  present  in 
the  anterior  wall  the  uterine  mucosa  is  found 
extending  into  the  depth  at  many  points, 
and  in  some  places  direct  continuity  with 
the  surface  can  b  e  traced  for  a  distance  of 
1.2  cm.  (Fig.  9).  Often  the  mucosa  is  recognized  as  islands  of 
mucous  membrane  far  down  in  the  myomatous  tissue  and  completely 
surrounded  by  it.  The  mucosa  throughout  the  myoma  differs  in 
no  way  from  that  lining  the  uterine  cavity.  The  glands  are  identical 
with  those  of  the  mucosa  and  are  surrounded  by  the  typical  stroma 
(Fig.  10).  The  picture  then  represents  a  diffuse  adenomyoma  of 
the  anterior  uterine  wrall  extending  almost  to  the  peritoneal  surface. 
That  the  gland  elements  are  derived  from  the  uterine  mucosa  is 
evident.  Histological  examination  of  the  tubes  shows  that  they 
are  very  slightly  altered. 

Diagnosis. — Diffuse  adenomyoma  of  the  anterior  uterine 
wall  with  the  presence  of  a  few  small  circumscribed  myomata. 
Right  side:  Slight  perisalpingitis;  normal  ovary.  Leftside:  Normal 
appendages. 

Gyn.  No.  12,080.     Path.  No.  8715. 
Chr  0  11  i  c     e  n  d  0  m  e  t  r  i  t  i  s  ;      d  i  f  f  u  s  e     a  d  e  n  0  m  y  - 
o  m  a    of    the    u  ferine    w  alls    w  i  t  h    direct    0  x  t  e  n  - 
si  on  of   the  mucosa   into   the  depth,   acute   puru- 


46  ADENOMYOMA   OF   THE    UTERUS 

lent  and  chronic  salpingitis;  general  pelvic 
adhesions. 

E.  B.,  aged  thirty,  colored,  married.  Admitted  April  28,  1905; 
discharged  June  17,  1905.  Complaint:  pain  in  the  lower  part  of 
abdomen.  Her  menses  began  at  twelve,  were  not  painful,  lasting 
several  days.  Her  periods  of  late  have  increased  in  duration;  the 
last  one  continued  for  fourteen  days.  She  has  been  married  thirteen 
years  and  has  had  six  children,  no  miscarriages.  The  youngest 
child  is  seven  months  old.  Deliveries  normal.  On  April  12,  1905, 
the  menstrual  flow  began  and  appeared  to  be  normal,  but  on  the 
fourteenth  day  the  patient  suddenly  felt  very  weak,  and  on  April 
17th,  while  doing  her  washing,  she  felt  a  sudden  severe  bearing- 
down  pain  in  the  lower  abdomen,  especially  on  the  right  side.  The 
pain  was  not  constant,  but  occurred  every  few  minutes.  Numerous 
clots  were  passed  at  this  time,  and  the  pain  became  so  severe  that 
the  patient  was  forced  to  come  to  the  hospital  for  relief. 

Note  of  May  22d :  This  patient  has  been  in  the  hospital  two  weeks. 
On  admission  she  apparently  had  peritonitis,  and  it  was  deemed 
wiser  to  delay  operation  for  a  time.  At  operation  a  large  pus  tube 
was  found  on  the  right  side.  This  curved  over  the  surface  of  an 
ovarian  cyst  and  passed  down  into  the  cul-de-sac  behind  the  uterus. 
On  the  left  side  a  large  pus  tube  could  be  seen  winding  out  to  the 
pelvic  wall.  This  curved  back  into  the  depth.  The  rectum  was 
adherent  to  the  base  of  the  broad  ligament  on  the  left  side  and  also 
to  the  posterior  surface  of  the  uterus.  The  upper  three-fourths  of 
the  uterus  was  free  from  adhesions,  but  below  this  point  the  organ 
was  firmly  fixed.  The  uterus  was  removed  with  a  great  deal  of 
difficulty. 

After  operation  the  patient  showed  signs  of  shock,  but  gradually 
improved,  and  was  discharged  on  June  17, 1905.  Her  temperature  on 
admission  was  101°  F.,  ran  a  regular  course,  reaching  its  highest  point, 
102.2°  F.j  on  June  2d.     From  this  time  it  gradually  dropped. 

Path.  No.  8715  . — The  specimen  consists  of  the  uterus, 
which  is  6  by  6  by  5  cm.  and  covered  with  many  adhesions,  espe- 
cially posteriorly.     The  uterine  walls  show  considerable  thickening. 


DIFFUSE    ADENOMYOMA    OF   THE    UTERUS  17 

( )  ii  e x a  m  i  m  a  t  i  o  n  of  I  h  e  s  I  i  d  e  w  i  I  h  I  li  <•  n  a  k  e d 
eye  it  is  possible  to  trace  the  uterine  mucosa 
fori  mm  .  into  the  depth  by  d  i  r  e  c  1   continuity. 

The  mucosa  has  an  intact  surface  epithelium.  This,  however,  is 
swollen  and  the  underlying  tissue  shows  a  great  deal  of  small  round- 
cell  infiltration,  especially  in  the  superficial  layers.  There  has  been 
a  chronic  endometritis.  The  glands  in  the  deeper  layers  are  perfect  ly 
normal.  At  the  junction  of  the  mucosa  with  the  muscle,  glands 
are  seen  penetrating  into  the  depth.  Examination  of  further 
sections  shows  practically  the  same  appearance  of  the  mucosa. 
There  are  dome-like  projections  which  extend  directly  into  the 
muscle  for  a  long  distance,  then  split  up  into  branches. 

Sections  from  the  tube  show  a  chronic  pyosalpingitis. 

Diagnosis  . — Chronic  endometritis,  diffuse  adenomyoma  of 
the  uterine  walls  with  the  glands  coming  from  the  mucosa;  acute 
purulent  and  chronic  salpingitis. 

Gyn.  No.  2806.     Path.  No.  334. 

Diffuse  adenomyoma  of  the  uterine  wall 
(Figs.  11  and  12).  Interstitial  and  subperito  n  e  a  1 
m  y  o  m  a  t  a  ,  general  pelvic  peritonitis.  R  i  g  h  t 
side,  tubo-ovarian  abscess.  Left  side,  healed 
salpingitis.      Hysterecto  m  y  .      Recove  r  y  . 

M.  G.,  widow,  white.  Admitted  May  30;  discharged  July  12, 
1894.  The  patient  entered  the  hospital  in  October,  1893,  when  a 
diagnosis  of  myomatous  uterus  was  made,  but  operation  was  not 
advised  at  that  time.  Since  then  the  patient  has  felt  well  until 
two  and  a  half  months  ago,  when  she  had  a  feeling  of  "her  womb 
being  out  of  position,"  followed  in  one  month  by  an  acute  attack  of 
pain  in  the  lower  abdomen.  Since  then  this  pain  has  been  constant. 
She  has  also  had  chilly  sensations  accompanied  by  sweating. 

Operation. — June  14,  1S94.  Hystero-myomectomy.  Dou- 
ble salpingo-oophorectomv.  The  myomatous  uterus  was  densely 
adherent  to  the  pelvis.  There  was  an  abscess  involving  the  left 
tube  and  ovary.     This  abscess  contained   lot)  c.c.  of  thick,  creamv, 


48 


ADENOMYOMA  OF   THE   UTERUS 


sterile  pus.  The  omentum  and  vermiform  appendix  were  adherent 
to  the  rectum.  The  patient  had  much  nausea  and  abdominal  pain 
after  operation,  and  there  was  great  nervousness,  and  at  times  a 
certain  degree  of  delirium. 

Gyn.-Path.     No.     334  . — The    specimen    consists    of    a 

moderately  enlarged  uterus 
with  adherent  appendages.  The 
uterus  is  8  by  7  by  7  cm. ;  it  is 
bright  red  in  color  and  every- 
where covered  with  dense  vas- 
cular adhesions.  On  its  anterior 
surface  are  two  myomata,  the 
one  2.5  cm.,  the  other  1.5  cm. 
in  diameter.  On  section  the 
cervical  mucous  membrane 
presents  the  usual  appearance. 
The  anterior  uterine  wall  aver- 
ages 2  cm.  in  thickness,  the 
posterior  slightly  less.  Situ- 
ated in  the  fundus  are  several 
small  my omata  (Fig.  11).  One 
of  these  encroaches  slightly 
upon  the  uterine  cavity.  At 
the  junction  of  the  cervix  with 
the  body  is  another  myoma  1.5 
cm.  in  diameter,  and  scattered 
throughout  the  walls  are  several 
minute  my  omata.  The  uterine 
cavity  is  2.5  cm.  in  length  and 
the  mucosa  is  scarcely  more 
than  1  mm.  in  thickness.  Right  side :  The  tube  is  17  cm.  in  length, 
densely  adherent  to  the  ovary,  and  reaches  2.5  cm.  in  thickness.  It  is 
filled  with  pus.  The  ovary  is  considerably  enlarged,  somewhat  cystic, 
and  is  the  seat  of  an  abscess  which  communicates  with  the  tube.  Left 
side :  The  tube  and  ovary  form  a  densely  adherent  mass  5  by  3  cm. 


Fig.  11. — Diffuse  adenomyoma  of  the  uterus 
with  several  discrete  myomata.  (Natural 
size.) 

Gyn.-Path.  No.  334.  This  is 
an  antero-posterior  section  of  the  uterus  and  to 
one  side  of  the  median  line,  as  we  are  only  able 
to  see  portions  of  the  uterine  cavity  a  and  a'. 
Situated  in  the  anterior  wall  and  fundus  are 
six  myomata,  and  in  the  posterior  wall  near 
the  cervix  there  is  a  small  interstitial  nodule. 
Both  uterine  walls  show  a  rather  coarse  arrange- 
ment of  the  muscle  and  the  posterior  wall  is 
somewhat  thickened.  The  uterine  mucosa  as 
seen  at  a  is  of  the  normal  thickness  and  appears 
to  be  unaltered.  For  the  histological  picture 
see  Fig.  12. 


DIFFUSE    ADEN0MY0MA    OF   THE    I  TER1  - 


11) 


•   ->-. 


... 


-  b 


Histological  Examination.  The  right  tube  is 
seen  to  be  the  seat  of  :i  salpingitis.  The  left  tube  also  shows  an 
inflammatory  process,  I  nil 
partial  healing  lias  taken 
place. 

The  chief  interest  lies  in 
the  condition  of  the  uterine 
mucosa.  The  surface  epithe- 
lium has  disappeared,  evi- 
dently owing  to  mechanical 
removal.  The  glands  are 
somewhat  degenerated,  prob- 
ably owing  to  faulty  harden- 
ing. Where  preserved,  they 
present  the  usual  appearance. 
In  places  there  is  small  round- 
cell  infiltration.  The  stroma 
as  a  whole  presents  a  wavy 
appearance.  Its  cells  have 
spindle-shaped  nuclei  which 
closely  resemble  those  of 
the  normal  muscle.  They 
also    run    in    definite    bun- 


c- 


w^.-SecA-c^ . 


Fig.    12. — Diffuse  adenomyoma   of   the    poste- 
rior uterine  wall.     (10  diameters. 

G  yn.-Path.  No.  334.  The  sect  ion 
dies.  They,  however,  Stain  isfromtheposteriorwallinFig.No.il.  o  repre- 
sents the  uterine  mucosa :  owing  to  imperfecl  harden- 
ing, the  surface  epithelium  is  wanting.  The  glands 
and  stroma  are.  however,  perfectly  aormal.  The 
uterine  walls  are  composed  of  myomatous  muscle. 
At  a!  the  mucosa  is  seen  penet rating  the  muscle, 
ami  scattered  throughout  the  deeper  portions  are 
cross-sections  and  longitudinal  sections  of  glands. 
These  are  surrounded  by  stroma  separating  them 
from  the  muscle.  At  b  the  stroma  around  the  gland 
seems  to  he  sending  off  prolongations  in  all  direc- 
tions.     The   dark    areas   <•   and   c'   are   also   area-  ol 

stroma,  hut  are  devoid  of  glands. 


more  deeply.  At  some 
points  isolated  glands 
or  bunches  of  g  1  a  n  d  s 
are  seen  extending 
d  o  w  n  i  n  t  o  t  h  e  m  u  s  - 
c  1  e  (Fig.  12).  These  glands 
present  the  usual  appearance 
and  most  of  them  are  sur- 
rounded by  stroma.  A  few,  however,  lie  in  direct  contact  with  the 
muscle  bundles.  Down  in  the  depth  the  muscle  is  gathered  up  into 
irregular  bundles  and  presents  the  characteristic  myomatous  appear- 


50  ADENOMYOMA    OF   THE    UTERUS 

ance.  Here  also  glands  are  present,  in  places  surrounded  by  the 
characteristic  uterine  stroma.  These  glands  are  found  at  a  distance 
of  at  least  1  cm.  from  the  uterine  cavity.  We  have,  then,  in  this 
uterus  faint  evidences  of  an  old  endometritis  and  diffuse  myomatous 
transformation  of  the  uterine  wall,  with  extension  of  the  uterine 
glands  into  this  myomatous  tissue,  especially  in  the  posterior  wall. 
As  was  noted,  there  are  also  well-defined  subperitoneal  and  inter- 
stitial myomata. 

Diagnosis  . — Subperitoneal  and  interstitial  uterine  myo- 
mata; diffuse  adenomyoma  of  the  uterine  wall;  general  pelvic 
peritonitis;  right  side,  tubo-ovarian  abscess;  left  side,  partially 
healed  salpingitis. 

Gyn.  No.  3204.     Path.  No.  526. 

Edema  of  the  uterine  mucosa;  commencing 
adenomyoma  in  the  body,  the  gland  elements 
coming  from  the  mucosa;  general  pelvic  ad- 
hesions;   small     ovarian     cyst. 

M.  S.,  married,  aged  thirty-six,  colored.  Admitted  November  22, 
1894;  discharged  January  15,  1895.  The  menses  began  at  four- 
teen; flow  regular,  lasting  from  three  to  five  days.  On  November 
11th  her  last  period  was  accompanied  by  severe  pain.  The  patient 
has  been  married  eleven  years  and  has  had  two  children  and  prob- 
ably one  miscarriage.  Following  this  there  seems  to  have  been 
puerperal  sepsis. 

Operation  . — Hystero-salpingo- oophorectomy.  The  patient's 
temperature  after  operation  was  101.5°  F.  It  gradually  fell,  but  on 
the  sixteenth  day  there  was  another  rise  to  101.6°  F.  The  pulse 
immediately  after  the  operation,  which  was  exceedingly  difficult, 
was  145,  but  gradually  fell  to  normal. 

Path.  No.  526  . — The  specimen  consists  of  the  uterus 
with  tubo-ovarian  masses  on  either  side.  The  uterus  measures 
7  by  5  by  5  cm.  Its  anterior  surface  is  smooth  and  glistening. 
Posteriorly  it  is  fastened  to  the  masses  on  either  side  by  broad 
vascular  adhesions.     The  under  cut  surface  is  2  cm.  in  diameter. 


DIFFUSE    AJDENOMYOMA    OF   THE    C7TER1  -  51 

The  cervical  mucosa  is  pale  and  glistening.  The  uterine  walls 
average  2  nun.  in  thickness  and  arc  pinkish-white  in  color  and  slightly 
striated.  The  uterine  cavity  is  5  cm.  Long;  at  the  fundus  it  is  2.5 
cm.  in  breadth.  The  mucosa  in  the  lower  part  is  yellowish-white. 
smooth  and  glistening,  but  in  the  fundus  presents  numerous  patches 
of  ecchymosis.     It  varies  from  3  to  5  mm.  in  thickness. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — The  uterine  mucosa 
in  the  vicinity  of  the  external  os  shows  small  round-cell  infiltration, 
but  otherwise  is  normal.  In  the  upper  part  of  the  uterus  the  mucosa 
is  considerably  thickened.  The  surface  epithelium  is  intact.  The 
glands  are  tortuous  and  abundant.  The  stroma  in  the  superficial 
portion  is  very  edematous,  but  in  the  deeper  portion  it  is  normal. 
With  the  low  p  o  w  e  r  the  m  u  c  o  s  a  a  t  m  a  n  y  points 
is  seen  extending  down  into  the  depth  and 
constrictions  are  forming,  almost  cutting 
off  some  areas  from  t  he  uterine  mucosa.  This 
can  be  traced  in  many  places  for  at  least  2  to  3  mm.  Some  of  the 
glands  are  dilated,  but  the  majority  are  perfectly  normal.  The 
uterine  muscle,  chiefly  beneath  the  mucosa,  is  being  divided  up  into 
whorls;  in  other  words,  the  appearances  suggest  myomatous  tissue. 
Where  the  glands  extend  into  the  depth,  they  are  usually  surrounded 
by  stroma,  but  in  some  places  lie  in  direct  contact  with  the  muscle. 

On  the  right  side  there  are  numerous  adhesions,  and  there  is  a 
unilocular  ovarian  cyst,  probably  a  dilated  Graafian  follicle.  On 
the  left  side  is  a  unilocular  cyst,  also  probably  a  Graafian  follicle. 
There  are  general  pelvic  adhesions. 

Diagnosis  . — Edema  of  the  mucosa ;  early  diffuse  adeno- 
myoma  of  the  body  of  the  uterus;  pelvic  adhesions  with  small 
bilateral  ovarian  cysts. 


CHAPTER  III 

CASES  OF  ADENOMYOMA  IN  WHICH  THE  UTERUS  RETAINS  A  RELA- 
TIVELY NORMAL  CONTOUR— (Continued) 

Gyn.  No.  3192.     Path.  No.  525. 

Commencing  diffuse  adenomyoma.  Adeno- 
myoma    of    the    left    uterine    horn. 

M.  D.,  white,  aged  forty-five,  married.  Admitted  November 
19,  1894;  discharged  December  15,  1894.  Complaint:  Pain  in 
the  lower  abdomen.  The  patient  has  had  frequent  attacks  of 
malaria,  but  otherwise  has  been  perfectly  healthy.  Her  menses 
began  at  nineteen  and  were  regular,  lasting  two  or  three  days.  For 
the  past  year,  however,  the  periods  have  occurred  every  three  weeks, 
and  there  has  been  considerable  pain  for  three  days  preceding  the 
onset  of  the  flow.  The  last  period  came  on  three  weeks  ago.  The 
patient  states  that  there  has  been  frequent  pain  and  a  thin  white 
but  not  copious  discharge.  She  has  been  married  twice,  the  first 
time  twenty-four  years  ago;  the  second  time  two  years  ago.  She 
has  had  five  children.  She  had  a  miscarriage  at  the  second  month 
eleven  years  ago.  For  the  past  year  the  patient  has  complained 
of  rather  severe  and  persistent  backache  and  pain  extending  down- 
ward and  reflected  to  both  lower  limbs.  Walking  or  any  exertion 
has  caused  an  aggravation  of  this  pain.  The  patient  appears  to 
be  debilitated  and  is  pale.     Her  appetite  is  poor. 

Operation  . — Hystero-salpingo-oophorectomy.  The  uterus 
was  enlarged  and  on  attempting  to  separate  the  adhesions 
the  bleeding  was  somewhat  profuse.  Convalescence  was  uninter- 
rupted and  the  patient  was  discharged  on  December  15th.  The 
highest  post-operative  temperature  was  100.5°  F. 

Path.  No.  525  . — The  specimen  consists  of  the  uterus, 
tubes  and  ovaries  intact.  The  portion  of  the  uterus  present  measures 
6.5  by  7  by  6  cm.     The  anterior  surface  over  its  lower  half  is  smooth 

52 


DIFFUSE    ADENOMYOMA    OF   THE    UTERI  -  53 

and  glistening.  The  upper  portion  of  the  anterior  surface  and  the 
posterior  surface  are  covered  with  rich  vascular  adhesions.  The 
uterine  muscle  averages  2.8  cm.  in  thickness  and  is  grayish-pink  in 

color  and  has  numerous  vessels  scattered  throughout  its  walls. 
The  Largest  of  these  is  2  mm.  in  diameter.  The  uterine  cavity  is 
3.2  cm.  long,  but  at  the  fundus  4  cm.  broad.  The  mucosa  is 
glistening,  somewhat  translucent,  but  on  the  left  side  presents  a 
Large  patch  of  ecchymosis. 

On  the  right  side  the  tube  at  the  uterine  cornu  measures  6  nun. 
in  diameter.  After  passing  outward  3  cm.  it  merges  into  a  tubo- 
ovarian  mass  5  by  4  by  1.5  cm.  This  is  too  mutilated  for  description. 
On  the  left  side  the  tube  is  8  cm.  long,  5  mm.  in  diameter  at  the 
uterine  extremity.  The  fimbriated  end  is  occluded;  it  measures 
1.5  cm.  in  diameter.  This  tube  is  free  from  adhesions.  In  the 
outer  end  of  the  parovarium  is  a  thin-walled  cyst,  2  cm.  in  diameter. 
This  is  covered  with  peritoneum  which  can  be  readily  shelled  off. 
It  is  seen  to  be  intimately  connected  with  the  parovarium.  The 
ovary  is  3  by  3  cm.  and  much  mutilated. 

Histological  Examination  . — The  uterine  mucosa 
varies  from  3.4  to  5  mm.  in  thickness.  The  surface  epithelium  is 
intact  but  somewhat  swollen.  The  glands  are  abundant  and  some- 
what tortuous.  In  a  few  places  they  are  dilated.  The  lumina  of 
the  glands  contain  a  small  amount  of  granular  material.  The 
glands  e  x  t  e  n  d  d  o  w  n  w  a  r  d  into  the  muscle  at 
numerous  points.  Most  of  these  are  surrounded  by  stroma. 
A  few,  however,  lie  between  muscle  bundles.  The  stroma  of  the 
mucosa  in  the  superficial  portion  is  lax,  but  scattered  everywhere 
throughout  it  are  lymphoid  cells  with  here  and  there  a  few  poly- 
morphonuclear leucocytes.  In  many  places  are  clear  spaces  rilled 
with  a  homogeneous  substance  which  stains  with  eosin.  The  uterine 
muscle  near  the  mucosa  is  being-  divided  up  into  myomatous  bundles, 
and  we  are  able  to  trace  the  mucosa  for  a  considerable  distance  into 
the  depth.  Just  beneath  such  areas  we  find  isolated  glands  and 
glands  surrounded  by  their  normal  stroma.  There  is  no  doubt  that 
we  are  dealing  with  a  commencing  adenomyoma. 


54  ADENOMYOMA  OF  THE  UTERI'S 

Examination  of  the  left  uterine  horn  shows  numerous  gland-like 
spaces  just  beneath  the  cross-section  of  the  tube.  These  in  many 
places  show  evidence  of  communicating  with  one  another.  The 
majority  of  them  are  irregular  and  are  lined  with  cuboidal  epithelium. 
The  epithelial  cells  lie  in  direct  contact  with  the  muscle.  At  other 
points,  however,  the  epithelium  is  separated  from  the  muscle  by  a 
faint  amount  of  stroma.  In  this  case  we  also  have  a  gland-like 
space  lying  just  beneath  the  peritoneal  adhesions.  This  space  is 
surrounded  by  muscle  and  has  a  lining  of  one  layer  of  cylindrical 
epithelium. 

Diagnosis  . — Diffuse  adenomyoma  of  the  uterus ;  adeno- 
myoma  of  the  left  uterine  horn. 

Gyn.  No.  5768.     Path.  No.  2066. 

A  d  e  11  0  m  y  o  m  a  occupying  both  the  anterior 
and  posterior  uterine  walls;  in  other  words, 
forming  a  complete  zone  around  the  uterine 
cavity  (Figs.  13,  14,  15,  and  16).  Hysterectomy. 
Recove r y . 

J.  W.,  single,  aged  thirty-eight,  white.  Admitted  January  3; 
discharged  January  31,  1898.  The  menses  commenced  at  fifteen, 
were  regular,  copious,  and  accompanied  by  many  clots.  The 
patient  has  had  severe  dysmenorrhcea  as  long  as  she  can  remember, 
this  being  more  pronounced  during  the  first  three  days  of  the  flow. 
She  has  had  a  rather  profuse  leucorrhceal  discharge,  occasionally 
yellowish-red  in  color.  The  bowels  are  constipated.  Micturition 
is  frequent  and  burning  and  she  has  pain  in  the  lower  abdomen, 
especially  on  the  left  side,  which  is  particularly  severe  at  the  men- 
strual period. 

The  outlet  is  intact,  the  uterus  about  7  cm.  in  diameter,  regular, 
hard  and  smooth. 

Operation  Jan.  5,  1898  . — Hystero-myomectomy. 
The  right  ovary  was  left  in  situ.  The  highest  post-operative  tem- 
perature was  100.6°  F.  The  pulse  did  not  rise  above  92.  She  made 
an  excellent  recovery. 


DIFFUSE    ADKNO.MYUMA    OF    THE    I  TER1  S 


.).) 


Gyn.-Pal  h  .  No.  2066.  The  specimen  consists  of  a 
pear-shaped  uterus,  considerably  enlarged.  This  has  been  amputated 
;t(  t Ik*  cervix;   ii  measures  s  cm.  in  length,  9  cm.  in  breadth,  and  8 


Uterine  cav. 

Fig.  13. — Diffuse  adenomyoma  of  the   uterus   involving   the  anterior   and  posterior 
walls  and  pundus.       ',  Datural  size.) 

Gyn.-Path.  No.  2  0  6(5.  The  uterus  has  been  amputated  through  the  cervix. 
Almost  the  entire  body  lias  been  transformed  into  a  diffuse  myomatous  growth  represented  by 
several  large  coarse  hands  of  fibres  with  many  smaller  bands  passing  off  from  them  and  winding 
in  every  conceivable  direction.  The  thickening  is  most  marked  in  the  anterior  wall,  where  the 
growth  extends  almost  to  the  peritoneal  surface.     There  is,  however,  a  thin  muscular  covering, 

as  indicated  bye.  The  lower  margin  of  the  growth  in  the  anterior  wall  is  indicated  by;.  In  the 
posterior  wall  the  growth  extends  downward  to 6.  The  entire  growth,  although  well  defined,  is  inti- 
mately blended  with  t  he  normal  muscle.  The  uterine  cavity  is  of  the  normal  length  and.  although 
there  are  a  few  inequalities  in  the  surface  of  the  mucosa,  it  is  comparatively  regular  and  of  normal 

t  hickness.  Fig.  II.  from  a  section  through  the  cut  ire  body  of  the  uterus,  illusl  rates  the  structure 
as  seen  with  the  low  magnification.     The  finer  details  are  shown  in  Figs.  1  •">  and  lti.     Clinically 

a  bimanual  examination  of  this  uterus  would  show  a  moderately  enlarged,  globular,  but  smooth, 
firm  fundus.      No  clue  would  be  gained  from  introducing  a  sound  into  the  uterine  cavitv. 


cm.  in  its  antero-posterior  diameter.  It  is  perfectly  smooth,  but 
has  a  rather  uneven  surface.  On  section  the  uterine  cavity  is  found 
to  be  6  cm.  in  length.     It  is  recognized  as  a  narrow  slit   (Fig.   13). 

Its  mucosa  is  of  the  normal  thickness  and  seems  unaltered.     The 


56 


ADENOMYOMA   OF    THE    UTERUS 


V/  a 


"S 


o^isf 


^J 


V 


'% 


^*i 


It  increase  in  size  of  the  uterus  is 

t  e^y  ;|:       due  to  a  diffuse  thickening  of 

its  walls.     This  is  general,  but 
more  prominent  in  the  ante- 
rior than  in  the  posterior  wall. 
The  anterior  wall  varies  from 
4  to  5  cm.  in  thickness,  the 
posterior   from  3   to  3.5  cm. 
This  diffuse  thickening  which 
is  found  in  both  uterine  walls 
.,i       consists  for  the  most  part  of 
gc>       myomatous  tissue.   Glistening 
j       bands  are  found  running  in 
I       and  out  in  all  directions  and 
I       forming  definite  whorls.    Scat- 


X^,         Fig.  14. — Diffuse  adenomyoma  of  the 

S  ANTERIOR     AND     POSTERIOR     UTERINE 

'^||  ay  alls.      (3  diameters.) 

Gyn.-Path.    No.    2066.      This 

is  an  antero-posterior  section  through  the 

entire  thickness  of  the  uterus  in  Fig.  13. 

. :,!     It  is,  however,  taken  nearer  the  side,  hence 

f  only  a  small  portion  of  the  uterine  cavity 

•"S*  ifl)  is  seen.     At  this  level  the  anterior  and 

posterior   walls    are    practically  of   equal 

.«  thickness.     The   myomatous  transforma- 

tion of  the  muscle  is  hardly  recognizable 
with  this  power.  At  b  the  uterine  mucosa 
is  of  the  normal  thickness,  but  at  c  can  be 
seen  penetrating  the  surrounding  muscle. 

.>-,  At  c'  it  can  be  followed  for  quite  a  distance. 

.  i  The  mucosa  penetrates  en  masse,  carrying 

with    it   the    normal    stroma.     Scattered 

V .-.*  throughout    both   walls,  but    more    par- 

ticularly the  anterior,  are  bunches  of  mu- 

I  §1         cosa.     These  are  well  shown  at  d  and  at  d' . 

£*-.■'.  We  can  trace  the  mucosa  in  its  windings 

for  a  considerable  distance.  A  goodly  num- 
ber of  isolated  glands  or  glands  in  small 
bunches  are  distributed  throughout  the 
walls.  At  e  are  several  dilated  glands 
0  £  with  little  or  no  intervening  stroma  separ- 

ating them  from  the  muscle.  /  is  a  dis- 
It  is  clearly  evident  that  the  glands  in  this  diffuse  myoma  are  due  to 


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£2 


v» 


V 


X 


crete  myomatous  nodule. 

down-growths  from  the  mucosa.     (For  the  finer  structures  of  the  adenomyoma  see  Figs.  15  and  16.) 


DIFFUSE    ADENOMYOMA    OF   THE    I  TER1  -  ■>, 

tered  everywhere  throughoul  the  growth  are  minute,  cyst-like  sp 
varying  from  a  pin-poinl  to  2  nun.  in  diameter. 

[  is  t  ologi  cal     E  \  a  m  i  n  a  t  ion  .     rhe    uterine   mucosa 


*   m 

"'•.V. 


K 
* 


■2  <>&% 


.■•/  I* 


Fk;.  15.     Method  of  penetration  of  the  mucosa  in  a  diffuse  adenomtoma  of  the  uterine 

wall.     (8  diameters. 

Gyn.-Path.  No.  2066.  The  section  is  from  the  body  of  the  uterus  in  Fig.  13. 
a  represents  the  thickness  of  I  he  uterine  mucosa.  The  surface  epithelium  has  been  mechanically 
losl  except  over  the  small  area  indicated  by  b.  The  uterine  glands  are  perfectly  normal.  A.1 
three  points,  however,  the  mucosa  can  be  seen  extending  into  the  underlying  myomal 
This  is  especially  well  marked  at  c,  where  a  Large  mass  of  the  normal  mucosa  is  flow  inn  into  the 
growth.  It  can  be  traced  to  the  lower  margin  of  the  section  at  <•'.  At  d  we  have  an  island  of 
mucosa  which  can  be  traced  upward  to  </':  in  other  words,  almost  t.>  the  mucosa.  The  island 
of  mucosa  (e)  resembles  in  every  particular  that  lining  the  uterine  cavity.  Here  and  th< 
gland  shows  some  dilatation. 

has  an  intact  surface  epithelium  which  presents  the  usual  appearance 
(Figs.  14  and  L6).  The  uterine  glands  arc  somewhat  convoluted, 
slightly    branching;,    and   are   lined    with   one    layer   of   cylindrical 


58 


ADENOMYOMA    OF   THE    UTERUS 


,$&S0?;. 


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Wh  Ska 

■■■-■  ■■■■-;  s  '■■>■-    .1 -.7 '....'  .\v  •.■...-•■■'.  ;■;>....    . ,' j;-  ■->;-■%.':,:;«, :-.•  '■■■■_:,- 


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Fig.  16. 


DIFFUSE   ADENOMYOJUA    OF    THE    UTERUS  59 

epithelium.     The  stroma  of  the  mucosa  is  normal  and  hereand  there 

an^  a  few  small  round  cells.  At  many  points  a  most  striking  picture 
is  noted.  The  mucosa  extends  down  into  the  underlying  muscle 
for  a  distance  of  1  cm.  or  more,  and  at  such  points  the  glands  are 
perfectly  normal  and  are  surrounded  by  the  characteristic  stroma 
of  the  mucosa  (Figs.  14,  15,  and  16).  It  looks  as  if  the  mucosa  were 
just  falling  down  quietly  into  the  clefts  between  muscle  bundles. 
The  diffuse  thickening  in  the  uterine  wall  is  due  to  a  myomatous 
transformation  of  the  muscle,  with  here  and  there  the  formation 
of  a  small,  sharply  circumscribed  myoma.  Scattered  everywhere 
throughout  this  myomatous  tissue  are  irregular  areas  of  uterine 
mucosa,  near  the  surface  directly  continuous  with  that  lining  the 
uterine  cavity,  but  in  the  depth  appearing  as  bands  of  mucous  mem- 
brane surrounded  by  myomatous  tissue.  The  glands  in  the  depth 
frequently  show  some  dilatation  giving  rise  to  the  cyst -like  spaces 
noted  macroscopically.  Nearly  all  of  the  glands  are  surrounded 
by  the  characteristic  stroma  of  the  mucosa. 

Covering  the  outer  surface  of  the  uterus  is  a  zone  of  normal 
muscle,  averaging  4  or  5  mm.  in  thickness.  This  is  totally  devoid 
of  gland  elements. 

The  case  is  a  most  instructive  one.  We  have  a  small  uter- 
ine cavity  s  u  r  r  o  u  n  d  e  d  o  n  all  si  d  e  s  b  y  n  o  r  m  a  1 
m  u  c  o  u  s  m  embrane.  This  m  u  cons  me  m  b  r  a  n  e 
h  a  s  a  n  o  u  t  e  r  c  o  v  e  r  i  n  g  v  a  r  y  i  n  g  from  3  t  o  5 
cm.     in     thickness    and     consisting     of     diffuse 


Fig.  16. — Extension  of  uterine  glands  into  the  diffuse  myomatoi  s  tissue  of  an  ldeno- 

myoma.      (")0  diameters.) 

Gyn.-Path.  No.  2066.  The  section  is  from  the  body  of  the  uterus  in  Kg.  13. 
a  represents  the  limits  of  the  mucosa;  the  surface  epithelium  is  intact  and  normal.  Them 
is  of  the  usual  thickness  and  its  glands  are  unaltered.  The  stroma  between  the  elands  is  slightly 
rarefied  in  the  superficial  portions  owing  to  a  slight  edema.  In  the  vicinity  of  6  are  a  number 
of  glands  lying  in  the  muscle.  At  c  we  have  fortunately  been  able  to  trace  a  gland  by  continuity 
from  the  mucosa  for  a  considerable  distance  into  the  diffuse  myoma.  It  divides  into  two  branches 
!<■').  which  extend  further  into  the  growth,  Accompanying  the  gland  c  are  d  and  e.  These  have 
been  much  convoluted,  as  only  occasionally  we  catch  a  glimpse  of  them,  at  </'  and  </"  and  <'  and 

e".  In  following  the  elands  <•,  d,  and  (  from  above  downward,  one  gathers  the  impression  that 
all  the  cross-sections  seen  in  the  lower  third  of  the  field  are  cross-sections  of  the  terminal  portions 
of  the  three  elands.  Accompanying  the  glands  and  separating  them  from  the  diffuse  myomatous 
growth  is  the  stroma  of  the  muc  sa. 


60  ADENOMYOMA   OF    THE    UTERUS 

myomatous  tissue  which  has  innumerable 
chinks  everywhere  traversing  it  and  allowing 
the  normal  mucous  membrane  to  flow  in 
and  fill  them  up.  The  whole  of  this  adeno- 
myomatous  mass  is  enveloped  in  a  thin  cap- 
sule of  normal  uterine  muscle. 

The  Fallopian  tubes  accompanying  the  uterus  are  normal. 

Diagnosis  . — Adenomyoma,  occupying  both  the  anterior 
and  posterior  uterine  walls;  in  other  words,  forming  a  complete 
zone  around  the  uterine  cavity.     Normal  Fallopian  tubes. 

Gyn.  No.  9457.     Path.  No.  5668. 

Multinodular  myomatous  uterus  with 
marked  adhesions:  Diffuse  adenomyoma  in 
the  fundus  with  a  definite  tendency  for  the 
mucosa  to  penetrate  into  the  muscle.  Dis- 
crete adenomyoma  near  the  uterine  horn. 
Ad  e  n  o  m  y  o  m  a  t  o  u  s  tissue  in  the  left  uterine 
wall  at  the  junction  of  the  broad  ligament. 
Large  cyst  of  the  right  ovary,  probably  un- 
dergoing  carcinomatous  transformation. 

M.  H.,  married,  white,  aged  forty-five.  Admitted  March  10, 
1902;  discharged  April  8,  1902.  Comes  for  removal  of  a  tumor 
and  cure  of  inguinal  and  umbilical  hernise.  For  the  past  year  the 
patient  has  menstruated  every  four  to  six  weeks,  and  recently 
there  has  been  a  yellowish,  non-irritating,  vaginal  discharge.  She 
has  been  married  eight  years,  has  had  no  children  and  no  miscar- 
riages. Three  or  four  years  ago  she  noticed  a  lump  in  the  right  lower 
abdomen.  This  has  greatly  increased  in  size  until  the  present  time. 
The  growth  has  apparently  been  more  rapid  during  the  last  six 
weeks. 

Operation  . — Pan-hystero-salpingo-oophorectomy  ;  radical 
cure  of  hernise,  the  abdominal  incision  extending  from  the  ensi- 
form  to  the  symphysis.  The  bowel  was  adherent  to  the  cyst  and 
also  at  the  hernial  ring.     The  ureters  were  misplaced  and  the  rectum 


DIFFUSE     \M.\n\l  Y<>\!.\    OF   THE    UTERUS  61 

was  adherenl  to  the  uterus.  The  cysl  was  everywhere  adherent 
to  the  lateral  abdominal  wall.  The  ureters  ran  from  the  pelvic  brim 
almost  straight  across  to  the  uterine  cornua,  being  aboul  5  to  6  cm. 
Long,  from  the  pelvic  brim  to  the  point  of  attachment  of  the  uterus. 

Each  ureter  was  dissected  free  for  a  distance  of  8  to  LO  cm.; 
then  the  adherenl  peritoneum  was  gradually  worked  away,  exposing 
the  uterine  vessels  which  were  tied.  The  right  ureter  was  accident  ally 
caughl  in  a  large  pair  of  artery  forceps  but  freed  two  or  three  minutes 
later.  The  patient's  convalescence  wyas  slow,  owing  to  her  great 
weakness.  She  was  discharged  well  on  the  twenty-eighth  day. 
Her  highest  temperature  after  operation  was  102°  F. 

Path.  X  o  .  5668  . — The  specimen  consists  of  the  uterus, 
left  tube  and  ovary,  and  a  very  large  ovarian  cyst.  The  uterus  is 
11  cm.  long,  9  cm.  broad,  and  is  covered  with  dense  adhesion-, 
some  of  which  contain  adipose  tissue.  Its  removal  has  evidently 
been  associated  with  great  difficulty.  The  enlargement  of  the  uterus 
is  clue  chiefly  to  the  presence  of  a  myoma,  9  by  8  cm.,  in  the  anterior 
wall.  There  is  also  a  nodule,  3  cm.  in  diameter,  situated  just  an- 
terior to  the  left  tube.  The  posterior  wall  of  the 
uterus  is  considerably  thickened  o  w  i  n  g  t  o 
the  presence  of  a  diffuse  myomatous  condi- 
tion. 

The  left  tube  and  ovary  are  enveloped  in  adhesions;  otherwise 
they  appear  normal.  The  right  tube  is  8  cm.  long  and  attached  to 
a  cyst.  The  cyst  is  approximately  20  cm.  in  diameter;  it  is  hard 
and  smooth,  but  is  covered  with  many  adhesions,  and  has  projecting 
from  its  surface  numerous  hard  nodules.  These  vary  from  3  to  4 
cm.  in  diameter.  On  section  they  are  whitish-yellow  in  color,  homo- 
geneous in  consistency,  and  divided  up  into  alveoli  by  a  septum  of 
connective  tissue.  The  cyst  walls  vary  from  3  to  4  cm.  in  thickness. 
The  inner  surface  is  in  places  smooth,  bul  at  numerous  points  the 
thickening  is  due  to  a  shaggy  growth  which  in  places  is  covered  by 
recent  clots.  At  one  point  is  a  nodule.  4  cm.  in  length  and  3  cm. 
in  breadth,  projecting  into  the  cavity.  This  nodule  is  porous  and 
closely  resembles  a  carcinomatous  growth. 


62  ADENOMYOMA   OF   THE    UTERUS 

Histological  Examination  . — Sections  from  the 
uterus  show  that  the  epithelium  is  intact.  The  mucosa  is 
normal  but  shows  a  decided  tendency  in 
places  to  penetrate  the  underlying  muscle 
en  masse.  Situated  just  posterior  to  the  left  uterine  cornu 
is  a  circumscribed  adenomyomatous  nodule,  fully  2  cm.  in  diameter. 
The  gland  elements  in  this  case  are  clearly  visible  to  the  naked  eye. 
The  islands  of  mucosa  vary  from  a  pin-point  to  2  or  3  mm.  in  length. 
They  differ  in  no  way  from  normal  mucosa.  Sometimes  isolated 
glands  are  found.  These  are  invariably  separated  from  the  muscle 
by  the  normal  stroma  of  the  endometrium.  A  few  of  the  glands  are 
dilated  and  are  filled  with  brownish  pigment.  The  nodule  is  very 
sharply  circumscribed  from  the  surrounding  tissue.  In  the  wall  of 
the  uterus  where  it  joined  the  left  broad  ligament  one  of  the  glands 
is  fully  3  mm.  in  diameter.  It  is  filled  with  pigment  and  fresh 
blood-cells. 

The  ovarian  cyst  has  an  inner  lining  of  one  layer  of  cylindrical 
epithelium.  At  many  points  there  has  been  hemorrhage  with  sub- 
sequent partial  organization  of  the  clots.  The  inner  epithelial 
lining  in  many  places  has  proliferated,  forming  new  glands,  and 
these  at  some  points  are  so  crowded  together  that  the  masses  of 
epithelial  cells  resemble  sarcomatous  tissue.  The  individual  cells 
are  fairly  uniform.  Some  of  them,  however,  are  considerably  en- 
larged and  stain  intensely.  Although  the  growth  may  be  now  con- 
sidered as  an  adenocarcinoma,  it  has  originally  been  a  simple  cyst. 

Diagnosis  . — Multinodular  myomatous  uterus  with  marked 
adhesions.  Diffuse  adenomyoma  of  the  fundus,  discrete  adeno- 
myoma.  Adenomyomatous  tissue  in  the  left  uterine  wall  at  the 
junction  of  the  broad  ligament.  Cyst  of  the  right  ovary  probably 
undergoing  carcinomatous  transformation. 

H.  A.  K.  Sanitarium  No.  469.     Path.  No.  1758. 
Diffuse    adenomyoma    of    both    the    anterior 
and    posterior    uterine    walls    with    the    glands 
coming    from    the    mucosa. 


DIFFUSE    AI)i;.\().MVO.MA    OF   THE    [JTERUS  63 

\V.   J.    R,.,    white,    married,    aged    fifty-five.      Admitted    May    21, 

ls(.)7;  discharged  .Inly  2,  ls(.)7.  The  patient  lias  bad  Bis  children. 
The  menses  began  at  nineteen  and  occurred  every  three  week-. 
They  were  very  free.  Eight  years  ago  she  had  a  prolapsus,  and 
during  the  last  year  it  has  been  excee< limply  diffirull  to  keep  the 
uterus  within  the  vagina. 

Operation.  — Hystero-salpingo-oophorectomy. 

The  uterus  was  removed  entirely.  The  patient  made  a  very 
satisfactory  recovery . 

Path.  X  o  .  1758  . — The  specimen  consists  of  the  uterus 
and  the  right  tube  and  ovary.  The  uterus  measures  9.5  l>y  7..") 
by  5  cm.  It  is  free  from  adhesions.  At  the  left  uterine  cornu  is  a 
myomatous  nodule  2.5  cm.  in  diameter.  The  cervical  canal  is 
2  cm.  in  length.  The  uterine  cavity  is  5.5  cm.  long.  The  mucosa 
lining  the  cavity  is  much  thickened  and  there  is  a  distinct  projection 
from  the  posterior  wall.  The  anterior  uterine  wall 
presents  a  diffuse  myomatous  appearance  a  n  d 
here  and  there  one  can  see  fine  porous  areas 
v  a  r  y  i  n  g  from  1  to  3  or  more  millimetres  i  n 
diameter.  At  some  points,  especially  at  the  fundus,  the 
mucosa  can  be  seen  with  the  naked  eye  extend- 
i  n  g  for  7  m  m  .  into  the  m  y  o  m  a  .  The  same  picture 
is  found  in  the  upper  part  of  the  cavity.  The  projection  from  the 
cavity  into  the  posterior  wall  is  due  to  a  diffuse  myomatous  thick- 
ening. The  posterior  wall  reaches  3.5  cm.  in  thickness.  Here  also 
are  a  few  porous  areas,  evidently  islands  of  uterine  mucosa. 

On  histological  examination  the  vaginal  por- 
tion of  the  cervix  is  found  to  be  normal.  Sections  from  the  anterior 
and  posterior  walls  show  normal  uterine  mucosa.  A  t  n  n  m  e  r  o  u  s 
points  this  mucosa  is  found  f  1  o  w  i  n  g  i  n  t  o  t  h  e 
U  n  d  e  r  1  y  i  n  g  m  y  o  m  a  .  This  is  c  1  e  a  r  1  y  d  e  m  o  n  - 
s  t  r a  b 1 e  thro  u g  h  o  u  t  the  e  n  t  i  r e  n  t  e  r i n  e  c a  v  i  t y . 
The  islands  of  mucous  membrane  everywhere  are  perfectly  normal 
save  for  dilatation  of  the  glands.  The  islands  are  most  abundant 
near  the  mucosa  and  are  totally  absent   in  the  vicinity  of  the  peri- 


64  ADENOMYOMA   OF   THE   UTERUS 

toneum.  We  have  here  another  example  of  a  diffuse  adenomyoma 
occupying  both  the  anterior  and  posterior  walls,  with  the  gland 
elements  everywhere  derived  from  the  uterine  mucosa. 

Gyn.  No.  2744.     Path.  No.  274. 

Diffuse  myomatous  thickening  of  the 
uterine  walls,  partly  of  the  adenomyomatous 
type  (Figs.  17  and  18) .  Well-defined  subperito- 
neal and  interstitial  myomata;  subacute 
endometritis;  slight  pelvic  peritonitis. 
Hysterectomy.      Recovery. 

S.  J.,  married,  aged  thirty-two,  colored.  Admitted  April  28; 
discharged  June  23,  1894. 

Menses  regular  up  to  two  years  ago,  since  when  they  have  in- 
creased in  frequency,  with  pain  at  the  periods. 

She  has  had  six  children,  four  still-born,  two  dying  at  seven 
months.  The  last  child  was  born  six  months  ago.  The  bowels  have 
been  constipated;  micturition  has  been  frequent.  For  the  past  year 
she  has  had  pain  in  the  left  side  and  back,  growing  gradually  worse. 

Examination  . — Five  distinct  myomata  could  be  felt  on 
the  surface  of  the  uterus,  varying  in  size  from  1  cm.  to  6  cm. 

Lips  and  mucous  membranes  pale.     Haemoglobin  39  per  cent. 

First  Operation  . — April  2,  1894.  Dilatation  and 
curetting.  Uterine  cavity  tortuous.  A  considerable  amount  of 
endometrial  tissue  was  removed.  The  patient  was  discharged  on 
April  13,  1894. 

Second  Operation  . — April  28,  1894.  Hystero-myo- 
mectomy.  Double  salpingectomy.  Incision  10  cm.  The  uterus 
was  myomatous  and  contained  irregular  and  nodular  masses,  which 
had  developed  mostly  from  the  posterior  wall  and  fundus.  There 
was  a  double  salpingitis  with  hydrosalpinx  and  double  peri-oophoritis. 
There  was  some  suppuration  of  the  abdominal  incision. 

The  temperature  varied  between  99°  and  102°  F.  for  nine  da}^s 
after  the  operation,  reaching  102.2°  F.  on  the  ninth  day.  Pulse 
80  to  114  (maximum  on  the  third  day).     The  temperature  for  a 


DIFFUSE    Al)l.\o\nii\l.\    OF   THE    I    I  ER1  - 


65 


month  occasionally  rose  to  L00c  I'.  The  pulse  was  below  88  after 
the  eleventh  day. 

Result  :   Recovery. 

Gyn.-Path.  No.  2  7  4.— The  specimen  consists  of  the 
uterus  and  appendages  intact.  The  uterus  has  been  converted  into 
an  irregular  mass  7  cm.  long,  8  cm.  from  side  to  side,  and  11  cm.  in 
its  antero-posterior  diameter.     It  is  pinkish  in  color,  smooth  and 


FlG.    17. — INTERSTITIAL   AM)    SUBPERITONEAL   UTERINE   MYoMATA.      INTERSTITIAL   ADENOMYOMA. 

(Natural  size.) 

Gyn.-Path.  No.  2  74.  This  is  an  antero-posterior  section  of  the  uterus.  The 
figures  a,  a,  a,  a,  indicate  myomata,  one  in  the  anterior  wall  and  three  in  the  posterior.  The 
anterior  wall,  not  implicated  by  the  myomata,  is  considerably  thickened.  The  organ  has 
amputated  through  the  cervix.  The  uterine  cavity  is  of  the  normal  length.  The  mucosa  of  the 
anterior  wall  is  much  thickened,  but  its  surface  is  relatively  smooth.  Some  of  the  glands  arc 
dilated,  forming  small  cysts.  The  mucosa  of  the  posterior  wall  is  little  altered,  but  it  also  shows 
some  glandular  dilatation.  The  area  represented  by  b  has  been  magnified  and  is  shown  in 
Fig.  18.     It  contains  a  small  diffuse  adenomyoma. 


ghstening.  Scattered  here  and  there  over  the  surface  are  bright 
red  vascular  adhesions.  Springing  from  the  posterior  surface  is  a 
firm  nodule.  5  cm.  in  diameter;  from  the  left  side  is  a  similar  one, 
2.5  cm.  in  diameter.  The  under  cut  surface  of  the  uterus  is  7  by  5 
cm.  iFi.u-.  17).  The  uterine  walls  average  3.5  cm.  in  thickness,  are 
pinkish  in  color,  and  contain  several  nodules,  the  largest  of  which  is 
2.5  cm.  in  diameter.  The  nodule  situated  in  the  posterior  wall 
and  also  those  scattered  throughout  the  uterus  are  pearly  white  in 


66 


ADENOMYOaIA    OF    THE    UTERUS 


appearance,  are  composed  of  concentrically  arranged  fibres,  and 
are  firm  and  non-yielding.  The  portion  of  the  uterine  cavity  present 
measures  2.5  cm.  in  length.  The  mucosa  is  apparently  1  mm.  in 
thickness,  is  pale  and  glistening,  and  in  places  presents  ecchymoses. 


Ji.  JBeefrei:  %&/ 


b 


Fig.  18. — Small  adexomyoma  in  the  fundus  of  the  uterus.     (3  diameters.) 

Gyn.-Path.  No.  274.  The  section  represents  the  area  b  seen  in  Fig.  17.  a  is  the 
upper  part  of  the  uterine  cavity;  b  is  the  thickened  mucosa  of  the  anterior  wall.  The  glands  on 
the  whole  are  normal,  except  that  there  is  dilatation  of  some  few  of  them.  The  line  of  demar- 
cation between  mucosa  and  muscle  is  irregular  and  not  well  defined.  The  glands  show  a  tendency 
to  invade  the  muscle,  c  represents  the  mucosa  in  the  posterior  wall.  This  is  thin,  and  there  is 
some  gland  dilatation,  but  the  mucosa  is  sharply  outlined  from  the  muscle.  At  d  there  is  a  regular 
colony  of  glands  deep  down  in  the  muscle.  They  bear  a  marked  resemblance  to  the  normal 
uterine  glands.  From  the  text  it  will  be  seen  that  some  of  them  are  surrounded  by  the  char- 
acteristic stroma  of  the  mucosa.  Others  lie  in  direct  contact  with  the  muscle.  The  surrounding 
tissue  and  the  uterine  walls  generally  are  made  up  of  a  diffuse  myomatous  tissue.  At  e  and  e'  are 
discrete  myomata. 


Near  the  fundus  is  a  polyp  1-5  cm.  in  diameter,  5  mm.  in  thickness. 
(The  uterus  was  curetted  one  month  ago.) 

Histological  Examination  . — A  description  of  the 
uterine  mucosa  is  unsatisfactory,  as  the  uterus  has  so  recently 
been  curetted.  Sections  from  portions  that  have  been  unmolested 
show  that  the  surface  epithelium  is  intact.     The  glands  are  few  in 


DIFFUSE    A.DENOMYOMA    OF   THE    I  TER1  -  <b 

Qumber  and  some  of  them  are  considerably  dilated.  The  Btroma 
of  the  mucosa  shows  a  good  deal  of  small  round-cell  infill  ration. 
At  several  points  n  e  a  r  the  f  u  n  <1  u  s  i  h  e  g  1  a  nd  a 
are  seen  extending  fully  3.5  mm.  into  the 
muscle1.  Here  they  are  somewhat  dilated,  bul  are  still  sur- 
rounded by  the  stroma  of  the  mucosa.  At  the  fundus  the  muscle 
contains  an  irregular  area  7  mm.  in  diameter  and  everywhere 
traversed  by  cyst-like  spaces  (Fig.  18).  These  represent  dilated 
uterine  glands  which  are  surrounded  by  a  small  amount  of  stroma. 
Scattered  throughout  such  an  area  are  also  numerous  glands  of 
normal  size.  These,  however,  lie  directly  between  muscle  bundles. 
The  epithelium  of  some  of  the  glands  stains  very  palely.  The 
thickening  in  the  uterine  walls  is  to  a  great  extent  due  to  a  diffuse 
myomatous  transformation  of  the  muscle.  The  nodules  scattered 
throughout  the  uterus  present  the  t}rpical  myomatous  appearance 
and  in  many  places  these  have  undergone  hyaline  degeneration. 

In  this  case  we  have  a  diffuse  myomatous  thickening  of  the  uterine 
walls  with  localized  infiltration  by  normal  uterine  mucosa:  also 
the  presence  of  several  well-defined  myomata.  The  right  tube  and 
ovary  are  covered  with  numerous  adhesions.  The  left  tube  and 
ovary  are  normal. 

Diagnosis  .—Subacute  endometritis,  diffuse  myomatous 
thickening  of  the  uterine  walls,  partly  of  the  adenomyomatous 
type;  well-defined  subperitoneal  and  interstitial  myomata;  slight 
pelvic  peritonitis. 

Union  Protestant  Infirmary  (Dr.  Russell).     Path.  No.  9858. 

Commencin  g  a  d  e  n  o  m  y  o  m  a  in  the  body  of 
the  uterus;  early  adenomyo  m  a  of  the  r  i  g  h  t 
u t  e  r  i  n e    ho  r n  ;    general  pelvi c  a  d h  e  s  i 0 n  s . 

The  specimen  consists  of  a  small  uterus  with  appendages.  The 
uterus  has  been  amputated  through  the  cervix  and  is  5  cm.  in  length. 
6  cm.  in  breadth,  and  4  cm.  in  its  antero-posterior  diameter.  The 
appendages  on  both  sides  are  thickened  and  adherent.  Projecting 
from  the  fundus  is  a  myoma,  3  cm.  in  diameter,  and  there  are  several 


68  ADENOMYOMA    OF   THE    UTERUS 

adhesions.  The  uterine  walls  are  slightly  thickened.  The  mucosa 
looks  normal.  The  right  tube  is  cystic  and  reaches  1  cm.  in  diameter 
near  its  outer  end,  where  it  is  adherent  to  the  slightly  enlarged  and 
cystic  right  ovary.  The  left  tube  and  ovary  are  enveloped  in  adhe- 
sions. 

Histological  Examination  . — The  surface  epithe- 
lium is  intact.  The  stroma  of  the  mucosa  is  normal.  At  some 
points  the  mucosa  is  seen  extending  into  the 
depth  for  a  short  distance  and  bands  of  myo- 
matous muscle  are  coming  in  and  gradually 
separating  off  this  mucosa  that  is  penetrat- 
i  n  g  the  d  e  p  t  h  .  The  underlying  muscle  is  more  wavy  than 
usual  and  looks  somewhat  myomatous.  It  is  evidently  a  very 
early  adenomyoma.  Sections  from  the  right  uterine  horn  show  that 
the  tube  at  this  point  is  normal.  The  muscle  just  beneath  shows  a 
distinct  myomatous  tendency.  Near  the  peritoneal  surface  and 
also  near  the  tube  are  gland-like  spaces,  some  of  them  occurring 
singly,  others  in  small  colonies.  These  gland-like  spaces  lie  in 
direct  contact  with  the  muscle  and  have  a  very  high  cylindrical 
epithelium.  Where  they  occur  in  groups  they  are  also  in  direct 
contact  with  the  muscle  and  are  lined  with  high  cylindrical  epithe- 
lium, in  each  case  surrounded  by  a  definite  zone  of  myomatous 
muscle.  Just  beneath  the  peritoneum  is  a  gland-like  space  lined 
with  cuboidal  epithelium.  Elsewhere  throughout  the  muscle  in  the 
vicinity  we  find  recent  myomata  which  are  being  gradually  differ- 
entiated from  the  normal  muscle. 

The  right  tube  shows  a  hydrosalpinx,  but,  apart  from  adhesions, 
nothing  abnormal. 

Diagnosis . — General  pelvic  adhesions  and  commencing 
adenomyoma  of  the  right  uterine  horn. 

Gyn.  No.  6083.     Path.  No.  2356. 
Diffuse     adenomyoma    involving     the    ante- 
rior wall,    left    side,    and   a   portion   of   the   pos- 
terior uterine  wall,  and  containing    miniature 


DIFFUSE    A l) ENOMYOM A    OF   THE    UTERUS 


(39 


u  beri  o  e   c  a  v  i  lies   jus!    b  e  n  e  a  I  h    I  h  e    p  enl  <»  n  e  a  1 
surface    (Figs.     L9,    20,    21.   and    22).     Hysterectomy. 

II  "e  covery. 

M.  T.,  married,  aged  twenty-three,  black.  Admitted  May  26, 
1898;  discharged  June  (>, 
1898.  She  complained 
of  an  enlargement  in  the 
lower  abdomen.  This 
was  associated  with  pain. 
She  had  had  one  child, 
no  miscarriages.  Men- 
struation had  been  regu- 
lar, every  four  weeks, 
lasting  from  four  to  five 
days;  flow  scanty.  She 
had  had  no  pain  until 
five  years  previously. 
Since  then  the  menses 
had  been  irregular  and 
the  flow  excessive,  last- 
ing at  times  for  two 
months  and  necessitat- 
ing her  remaining  in 
bed. 

At  present  the  pain 
in  the  lower  abdomen 
is  sharp  and  intense. 
During  the  last  month 
there  has  been  con- 
stant   bleeding,    except 


Fig.  19.- 


(Nat- 


-DlFFUSE  ADEXOMYO.MA  OP  THE    UTERI'S. 

ural  size.) 

Gyn.-Path.  X  o  .  2  3  5  6.  The  section  is  an  an- 
teroposterior one  through  the  left  side  of  the  uterus.  At 
this  point  nearly  the  entire  uterine  wall  is  composed  of  a 
diffuse  myomatous  growth.  At  points  a.  a.  however,  a 
small  amount  of  normal  uterine  muscle  remains.  In  other 
places  the  growth  reaches  the  peritoneum.  Scattered 
throughout  the  myoma  are  round,  oval,  irregular  or  slit- 
like cavities  with  smooth  inner  linings.  Tiny  are  most 
abundant  and  reach  their  greatest  diameters  just  beneath 
the  peritoneum.  Here  they  have  a  lining  resembling  mu- 
cosa which  in  places  reaches  1  nun.  or  more  in  thickness. 
The  two  cyst  spaces,  seen  at  b,  an-  in  reality  merely  two 
cross-sections  of  one  convoluted  cavity.  See  Fig.  21.) 
At  <■  one  of  the  cyst-like  spaces  ran  be  traced  as  a  -lit  for 
a  considerable  distance  into  the  growth.  On  histological 
examination  the  large  cyst-like  spaces  proved  to  be  mini- 
ature uterine  cavities.     (See  Figs.  2]  and  22. 


for  intervals  of    two   or 

three  days.     There  is  no  increase  in  frequency  of  micturition. 

The  lower  half  of  the  abdomen  is  distended  and  there  is  marked 
tenderness  on  the  left  side,  as  well  as  in  the  inguinal  and  hypo- 
gastric regions.     The  outlet   is  well  lifted  up.   the  cervix  is  small. 


70  ADENOMYOMA   OF   THE    UTERUS 

The  os  admits  the  index-finger  and  the  uterus  is  represented  by  a 
mass  approximately  10  cm.  in  diameter.  The  lateral  structures 
cannot  be  outlined. 

Operation  . — Hystero-myomectomy.  The  patient  made  a 
perfect  recovery. 

Path.  No.  2356  . — The  left  side  of  the  fundus  shows  some 
faintly  raised  bosses,  which  can  be  traced  a  short  distance  over  the 
left  posterior  aspect.  They  are  slightly  yielding  on  pressure.  The 
uterine  cavity  is  4.5  cm.  in  length  and  3.5  cm.  in  breadth  at  the 


:v 


*$&,.         ::, , 


mm 


Fig.  20. — Diffuse  adenomyoma  of  the  uterine  wall.     (4  diameters.) 

Gyn  -Path.  No.  2356.  The  section  is  from  the  body  of  the  uterus.  A  glance  at  a 
shows  that  the  mucosa  is  very  thin  and  that  some  of  the  glands  are  dilated.  At  &  is  a  small 
polypoid  outgrowth  consisting  of  normal  mucosa.  The  uterine  wall  is  transformed  into  the 
diffuse  myomatous  growth.  At  c  the  normal  mucosa  is  seen  extending  for  quite  a  distance  into 
the  diffuse  myoma,  and  at  points  d,  d,  we  have  islands  of  the  mucosa  in  the  depth.  At  e  there  is 
considerable  gland  dilatation.  Distributed  here  and  there  are  isolated  glands  accompanied  by 
their  stroma,  and  at  /  is  an  island  of  stroma  devoid  of  gland  elements.  The  glandular  elements  of 
this  diffuse  adenomyoma  have  undoubtedly  arisen  from  uterine  glands. 

fundus.  The  mucosa  has  a  roughened  surface,  is  about  2  mm.  in 
thickness,  and  has  springing  from  it  several  small  polypi,  varying 
from  2  to  8  mm.  in  length.  The  posterior  uterine  wall 
varies  from  2.5  to  3  cm.  in  thickness.  It  is 
easily  divisible  into  two  portions;  an  inner, 
about  2.5  cm.  in  thickness,  very  dense  in 
character,  consisting  of  strands  running  in 
all  directions  and  closely  resembling  myo- 
matous tissue.  This  can  be  traced  as  far  as 
the    mucosa,    but    is    easily    differentiated    from 


DIFFUSE    A.DENOMYOMA    OF    THE    I  TER1  S  ,  1 

it.  T  h  e  o  u  t  c  r  p  o  r  i  i  o  n  o  f  t  h  e  p  o  s  t  e  r  i  o  r  w  a  1  1 
c  o  n  s  i  s  i  a  o  f  ii  o  r  m  a  1  uteri  n  e  m  u  s  cle  .  The  anterior 
uterine  wall  is  aboul  4  cm.  in  thickness  and  differs  materially  from 
the  posterior.  It  consists  almost  entirely  of  coarse  bands  of  tissue 
running  in  all  directions  and  forming  definite  whorls.  In  the  fresh 
state,  small  cyst-like  spaces  were  seen  scattered  throughout  the 
myomatous  tissue,  but  the  differentiation  was  not  marked.  After 
hardening  in  .Midler's  fluid,  however,  these  cyst-like  spaces,  which 
vary  from  .5  to  5  mm.  in  diameter,  are  found  to  be  situated  in  a 
fairly  homogeneous  tissue  devoid  of  fibres  and  totally  different  from 
the  surrounding  myomatous  tissue.  Furthermore,  in  this  homo- 
geneous tissue  are  many  small  openings,  somewhat  punctiform  in 
character.  These  areas  resemble  uterine  mucosa,  and  on  examining 
the  mucosa  of  the  anterior  wall  we  can  at  some  points  see  the  mucous 
membrane  penetrating  the  muscle  for  at  least  4  mm.  These  islands 
of  homogeneous  tissue,  which  resemble  mucosa,  vary  greatly  in 
shape.  Some  are  comparatively  round,  others  oblong,  but  the 
majority  are  triangular  (Fig.  19).  They  are  abundantly  scattered 
throughout  the  myomatous  tissue.  The  growth  occupying  the 
thickened  anterior  uterine  wall,  and  consisting,  as  we  have  seen,  of 
myomatous  tissue  and  islands  of  mucosa,  also  involves  the  left  side 
and  to  some  extent  the  left  posterior  aspect  of  the  uterus.  It  has 
an  outer  covering  of  uterine  muscle,  averaging  3  mm.  in  thickni  - 
But  at  the  points  at  which  we  noted  the  bosses  on  the  left  and  pos- 
terior aspects  of  the  uterus  it  has  practically  reached  the  peritoneal 
surface.  On  making  an  antero-posterior  section  through  the  uterus, 
near  the  insertion  of  the  left  tube,  it  is  seen  that  the  diffuse  myoma 
contains  several  irregular  cyst-like  spaces  a  short  distance  beneath 
the  peritoneal  covering.  The  largest  of  these  is  6  mm.  in  diameter. 
All  have  smooth  inner  linings  which  resemble  mucous  membrane. 
This  inner  covering  is  fully  .5  mm.  in  thickness. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — Sections  from  the 
posterior  wall  of  the  uterus  in  the  mid-line  show  that  the  surface  i^\ 
the  mucosa  has  in  part  disappeared.  The  underlying  glands  show 
no  change,  but  the  muscle  directly  beneath  the  mucosa  reveals  con- 


72 


ADENOMYOMA   OF   THE    UTERUS 


siderable  proliferation  of  the  connective  tissue  around  the  smaller 
blood-vessels.  The  muscle  bundles  are  denser  than  usual  and  show 
a  greater  tendency  to  wind  in  and  out.     No  glands  are  demonstrable 

f 


,a 


^..    -  ■—=--- .J-b-v  -■-"-"■- tr-1; 


m  e 


fta* 


"~$£.3ec7zer. 


Fig.  21. — Cyst-like  spaces  just  beneath  the  peritoneum  in  a  diffuse  adenomyoma  of  the 

uterus.     (12  diameters.) 

Gyn.-Path.  No.  2356.  The  section  represents  the  area  b  in  Fig.  19.  a  is  the  thin 
outer  covering  of  normal  muscle;  a'  the  peritoneum,  b  is  one  of  the  cyst-like  spaces;  it  is  lined 
with  a  definite  mucosa.  This  mucosa  has  a  surface  epithelium  and  beneath  it  a  mucous  mem- 
brane containing  many  glands.  The  majority  are  small  and  round.  Some  of  them  are.  however, 
dilated  and  convoluted.  For  the  finer  structures  see  Fig.  22,  which  is  the  area  c  much  enlarged. 
The  mucosa  cannot  be  distinguished  from  the  normal  uterine  mucosa  and  the  entire  cyst  resembles 
a  small  uterine  cavity.  At  d  is  an  area  of  mucosa  identical  with  that  normally  found  lining  the 
uterine  cavity,  e,  e' ,  e" ,  e'"  are  evidently  cross-sections  of  one  cavity  which  is  much  convoluted. 
The  mucosa  in  them  resembles  that  lining  the  cavity  b.  The  cyst  space  b  and  those  represented 
by  e,  e',  e" ,  e'"  are  also  evidently  part  of  the  same  cavity  as  seen  by  the  connecting  link  of  the 
mucosa  /. 

in  the  muscle.  The  mucosa  of  the  anterior  wall  has  also  lost  its 
surface  epithelium  except  at  protected  points.  This  loss  is  un- 
doubtedly due  to  the  faulty  preparation  of  the  specimen.     The  glands 


DIFFUSE    ADENOMYOMA    OF   THE    UTERUS  76 

in  the  mucosa,  on  the  whole  are  normal.  A  few  of  them,  however, 
arc  dilated.  At  one  point  the  mucosa  is  seen  ex- 
t  e  n  (1  i  n  g  4  in  in  .  into  t  h  e  u  n  d  e  r  1  y  i  n  g  m  us  c  1  e 
(Fig.  20).  Here  the  glands  and  stroma  seem  to  penetrate  ill  the 
form  of  a  wedge,  and  the  muscle  is  to  some  extent  arranged  parallel 
with  this  entering  wedge.  The  thickened  anterior  uterine  wall  is 
composed  of  myomatous  tissue  presenting  the  usual  appearance  and 
traceable  up  to  the  mucous  membrane.  Scattered  freely 
throughout  the  myomatous  tissue  are  islands 
of  g  1  a  nd  s  .  These  glands  are  usually  circular  or  oblong  in  form 
and  lined  with  one  layer  of  fairly  high  cylindrical  ciliated  epithelium. 
They  are  invariably  surrounded  by  stroma  similar  to  that  of  the 
uterine  mucosa.  In  fact,  they  appear  to  be  nothing  more  than 
large  and  small  islands  of  uterine  mucosa  scattered  throughout  the 
myomatous  tissue.  Some  of  the  glands  are  dilated,  and  where  such 
dilatation  has  occurred,  the  epithelium  is  usually  paler  and  somewhat 
flattened.  Such  glands  often  contain  desquamated  epithelial  cells 
and  granular  material — evidently  coagulated  serum.  A  few  of  the 
desquamated  cells  contain  pigment  droplets,  the  result  of  an  old 
hemorrhage.  Occasionally  Ave  find  an  isolated  gland  in  the  muscle 
or  a  small  amount  of  stroma  lying  alone  between  muscle  bundles. 
The  muscle  covering  the  outer  surface  of  this  diffuse  myoma  is 
normal. 

The  large  cyst-like  spaces  seen  in  the  my- 
oma in  the  vicinity  of  the  left  horn  are 
throughout  lined  with  m  ucous  m  e  m  b  r  a  n  e 
identical  with  that  of  the  uterine  mucosa 
(Figs.  21  and  22).  The  inner  surface  of  each  has  a  covering  of  one 
layer  of  epithelium,  cylindrical  in  character,  except  where  the  space 
is  very  much  dilated.  Here  the  epithelium  is  pale-staining  and 
cuboidal  or  almost  flat.  Occasionally,  there  is  a  little  tuft  of  epithe- 
lium projecting  into  the  cavity,  but  the  individual  cells  of  such 
tufts  are  in  no  way  suspicious.  Here  and  there  the  epithelium  is 
raised  by  an  old  blood-clot  which  is  partially  organized.  Beneath 
the  epithelium  are  typical  uterine  glands,  normal  in  appearance  and 


74 


ADENOMYOMA    OF    THE    UTERUS 


separated  by  the  characteristic  stroma  of  the  mucosa.  If  we  were  to 
take  a  section  through  a  portion  of  one  of  these  cyst  walls,  it  would 
be  impossible  to  differentiate  it  from  the  mucosa  lining  a  normal 
uterine  cavity  (Fig.  22). 

We  have  in  this  uterus  a  diffuse  adenomy- 
oma  consisting  of  coarse  myomatous  tissue, 
everywhere     invaded     by     islands     of     uterine 


&=■<--< 


j  b 


d  a 

Fig.  22. — The  mucosa    lining  one  of  the   cyst-like  spaces  situated  just   beneath  the 

PERITONEUM   IN  A   DIFFUSE   ADENOMYOMA   OF   THE   UTERUS.       (85   diameters.) 

Gyn.-Path.  No.  2  3  56.  The  section  is  the  area  c  in  Fig.  21  much  enlarged,  a 
represents  the  mucosa;  b,  the  myomatous  muscle.  The  surface  of  the  mucosa  is  comparatively 
regular  and  is  covered  by  a  single  layer  of  cylindrical  epithelium.  At  two  points  glands  are 
seen  opening  on  the  surface.  The  glands  of  the  mucosa  are  round  or  oval  on  cross-section,  and  are 
lined  with  cylindrical  epithelium.  Surrounding  the  glands  and  separating  them  from  the  muscle 
is  a  definite  stroma.  In  this  the  endothelial  cells  of  the  blood  capillaries  are  moderately  swollen. 
c  is  a  gland  showing  some  branching;  d  and  d  are  the  bases  of  glands  so  cut  as  to  resemble  solid 
nests.  This  mucous  membrane  resembles  uterine  mucosa  in  every  particular,  and  given  such  a  sec- 
tion, not  knowing  its  source  of  origin,  we  should  unhesitatingly  say  that  it  was  normal  mucosa 
from  the  uterine  cavity. 

glands,  differing  in  no  way,  except  for  their 
dilatation,  from  normal  uterine  mucosa. 
The  growth  occupies  the  entire  anterior  uter- 
ine wall,  the  left  side,  and  also  the  left 
portion  of  the  posterior  wall.  This  diffuse 
adenomyoma  has,  as  was  noted,  an  outer 
covering    of    uterine    muscle,    but    on    the    left 


DIFFUSE    ADEN0MY0MA    OF   THE    [JTER1  -  1 5 

s  i  (1  e  b  a  s  r  cached  the  s  u  r  f  a  c  e  and  i  b  r  e  c  o  g  - 
aized    as   small    bosses.      The  growth  is  certainly  benign. 

Gyn.  No.  3136.     Path.  No.  497. 
Diffuse    a  d  e  n  0  m  y  0  m  a    o  f    t  h  e    a  n  t  e  r  i  o  r    uter- 
ine   wall     (Figs.   23,   24,   25,   26).     Glandula  r    u  t eri  n  e 

poly});  small  interstitial  an  d  subperitoneal 
myomata.     Hysterecto  m  y  .      Recover  y  . 

L.  W.,  aged  forty-six,  white,  single.  Admitted  October  24,  1894. 
Complaint :  Pain  in  lower  part  of  the  abdomen,  painful  and  profuse 
menstruation.  Menstruation  commenced  when  she  was  eleven 
years  of  age  and  was  always  regular.  For  the  past  ten  years  she 
has  had  severe  pains  in  the  right  ovarian  region  at  the  menstrual 
period.  These  pains  radiated  down  both  limbs,  were  accompanied 
by  backache,  and  for  the  last  two  years  have  been  so  severe  that  she 
has  been  confined  to  bed  for  three  or  four  days  at  each  period.  At 
present  the  flow  lasts  from  ten  days  to  two  weeks  and  there  is  a 
considerable  amount  of  clotted  blood.  Her  last  period  ceased  one 
week  before  admission.  Her  parents  are  both  living  and  healthy. 
One  brother  died  of  tuberculosis.  With  the  exception  of  an  attack 
of  diphtheria  several  years  ago  and  influenza  three  years  ago,  she  has 
always  been  well. 

Present  Condition. — The  patient  is  a  rather  anaemic 
woman  and  does  not  appear  to  be  very  strong.  Her  tongue  is  pale 
and  flabby;  the  appetite  is  fair,  the  bowels  are  regular.  She  is 
unable  to  walk  much  and  cannot  lift  heavy  weights.  Vaginal  ex- 
amination: The  outlet  is  very  much  relaxed,  and  presenting  at  the 
orifice  is  a  hard,  irregular  mass  which  proves  to  be  the  cervix.  The 
external  os  is  patulous,  admitting  the  index-linger,  and  projecting 
from  the  os  is  what  appears  to  be  a  myomatous  nodule  about  2  cm. 
in  diameter.  The  cone-shaped  cervix  is  continuous  with  the  en- 
larged uterus,  which  is  apparently  freely  movable. 

Clinical    Diagnosis  . — Myoma . 

Operation  Oct.  31,  1894  . — On  opening  the  abdo- 
men it  was  found  impossible  to  raise  the  uterus  out  of  the  pelvis, 


76  ADENOMYOMA   OF   THE    UTERUS 

and  the  operator  was  compelled  to  work  in  the  narrow  space  between 
the  uterus  and  the  pelvic  walls.  The  ovarian  and  uterine  vessels  on 
both  sides  were  controlled  and  the  uterus  was  amputated.  The  lips 
of  the  stump  were  then  brought  together,  and,  lastly,  the  peritoneum 
from  the  posterior  wall  was  sutured  to  that  of  the  anterior,  thereby 
completely  covering  over  the  stump.  The  patient  made  an  un- 
interrupted recovery,  and  was  discharged  December  1,  1894. 

Gyn.-Path.  No.  497  . — The  specimen  consists  of  the 
enlarged  uterus  with  its  tubes  and  ovaries  intact.  The  uterus 
is  13  cm.  long,  12  cm.  broad,  and  10  cm.  in  its  antero-posterior 
diameter.  It  is  approximately  globular  and  in  its  contour  resembles 
a  normal  but  enlarged  uterus.  Anteriorly  it  is  smooth  and  glisten- 
ing; posteriorly  over  its  lower  two-thirds  it  is  denuded  of  peritoneum. 
Situated  in  the  posterior  wall  in  the  vicinity  of  the  left  uterine  cornu 
are  four  sessile  nodules,  which  are  approximately  circular.  The 
largest  of  these  is  2  cm.  in  diameter.  On  section  they  are  whitish 
in  color  and  are  composed  of  fibres  concentrically  arranged.  They 
present  the  usual  myomatous  picture.  The  under  cut  surface  of 
the  uterus  measures  12  by  11  cm.  In  the  centre  of  this  is  the  cer- 
vical opening,  which  is  1  cm.  in  diameter.  Projecting  from  the 
right  side  of  this  opening  is  a  nodule  2.5  cm.  in  diameter;  this  is 
apparently  covered  with  mucous  membrane  which  is  somewhat 
hemorrhagic. 

The  anterior  uterine  wall  is  7  cm.  in  thick- 
ness (Fig.  23) ;  it  can  be  divided  into  two  dis- 
tinct portions;  the  outer,  1  cm.  thick,  re- 
sembles normal  uterine  muscle;  the  remain- 
der of  the  wall  presents  a  coarsely  striated 
appearance,  the  striae  running  in  all  direc- 
tions. Scattered  throughout  this  thickened 
and  striated  portion  of  the  uterine  wall  are 
round,  oval,  or  elongate,  brownish-yellow, 
homogeneous  areas,  some  of  which  merge 
directly  into  the  uterine  mucosa.  In  one 
or    two    places    small    cysts,  varying    from    1    to 


DIFFUSE    A  l>i;\n.\IY<).\I.\    OF   THE    UTERUS 


t  < 


I  in  in  .  ,  c  a  n  I)  e  s  c  e  n  s  c  a  t  I  o  r  e  d  I  li  r  o  U  g  li  oul  I  li  i  B 
t  h  i  c  k  e  n  e  (I  p  o  r  t  i  o  n  o  I"  t  h  e  u  t eri  d  e  w  all .  T  h  e 
s  t  r  i  a  t  e  d    a p p  e  a  r  a  n  c  e    c  an     be     traced    d  i  r  e  c  I  1  y 


Fig.   23. — Dikfush  aoenomyoma  of  the  anterior  vtkkixk   wall.     i|:   natural  >i 

Gyn.  No.  497.  The  uterus  has  been  cut  open  and  is  seen  from  tin-  fr<  mt .  The  drawing 
is  from  the  specimen  hardened  in  Mtiller's  fluid.  A  small  portion  of  the  cervix  is  present.  Pro- 
jecting through  the  cervical  opening  is  a  globular  nodule  u/)  whose  pedicle  springs  from  the  uterine 
Cavity  just  within  the  internal  OS.  Oil  histological  examination  this  was  found  to  be  a  myoma 
everywhere  penetrated  by  glands.  The  anterior  uterine  wall  is  much  thicker  than  usual.  It  is 
divisible  into  two  portions,  an  inner  coarsely  striated  and  an  outer  In  it  narrower  zone  which  is  the 
normal  uterine  muscle.  This  miter  zone  presents  a  parallel  arrangement  of  its  muscle  bundles. 
( )n  examining  the  fundus  carefully  the  coarse  st  nation  is  seen  to  be  con  lined  to  the  anterior  wall. 
The  uterine  mucosa,  apart  from  slight  undulation  of  the  surface,  is  smooth.  The  small  folds 
described  as  occurring  near  the  internal  os  are  obscured  by  the  polyp.  I  >ne  of  the  most  striking 
features  is  that  there  is  practically  no  encroachment  of  the  growth  on  the  uterine  cavity,  the 
anterior  wall  showing  little,  if  any.  convexity.  This  is  in  marked  contrast  to  what  takes  place 
in  cases  of  submucous myomata.     For  the  histological  picture  see  Figs.  24,  25,  and  _'o. 

u  p   t  o   t  h  e   u  t  e  r  i  n  e   m  u  c  o  s  a  ,   a  n  d   in   s  o  m  e   p  1  a  c  e  s 
i  n  t  o    it.     After  hardening   the  specimen   in   Midler's  fluid   the 

contrast   between    the    normal    uterine   muscle   and    the   thickened 


78 


ADENOMYOMA    OF    THE    UTERUS 


=  y^4     ■'-    i  &i    '7     P*     ' 


v> 


jiffy:  ^|§C^^F«^: 


P- 


^1 


striated  portion  is  very  sharp,  the 
uterine  muscle  being  much  darker 
in  color  than  the  striated  portion. 
The  posterior  wall  of  the  uterus  varies 
from  2.5  to  3.5  cm.  in  thickness.  It 
is  rather  dense,  but  does  not  present 
any  coarse  striations.  Situated  in 
the  posterior  wall  are  two  interstitial 
nodules  1  and  1.5  cm.  in  diameter; 
they  are  pearly  white  in  color  and 
are  composed  of  concentrically  ar- 
ranged fibres. 

Fig.  24. — Diffuse  adenomyoma  of  the  anterior 
uterine  wall.      (3  diameters.) 

Fig.  24  is  a  cross-section  from  the  thickened  an- 
terior uterine  wall  in  Fig.  23.  a  indicates  the  uterine 
mucosa,  b  the  adenomyomatous  zone  and  c  the  nor- 
mal outer  covering  of  uterine  muscle.  The  surface 
of  the  mucosa  presents  a  wavy  outline.  The  surface 
epithelium  is  intact  and  the  glands  are  for  the  most 
part  normal  in  size.  A  few  of  them  are  dilated,  one 
reaching  a  considerable  size.  On  passing  to  the  mus- 
cle large  numbers  of  longitudinal  glands  are  seen 
penetrating  downward  into  the  growth  between  the 
muscle  bundles.  These  are  surrounded  by  a  tissue 
darker  than  the  muscle — the  typical  stroma  of  the 
mucosa.  The  greater  part  of  the  specimen  is  com- 
posed of  bundles  of  muscle  fibres.  Some  of  the  bun- 
dles present  a  circular  arrangement,  others  are  ob- 
long and  some  wind  in  and  out  in  all  directions. 
These  large  bundles  are  again  subdivided  into 
smaller  ones.  Scattered  everywhere  through  the 
thickened  zone  are  dark  areas.  Some  of  these  are 
triangular;  some  are  semicircular,  while  others  are 
irregular  in  shape.  On  examining  these  areas  closely, 
the  majority  are  found  to  contain  longitudinal  or 
cross-sections  of  glands.  Some  of  these  glands  are 
dilated  and  irregular  in  contour.  A  longitudinal  sec- 
tion of  a  gland  with  a  dilatation  on  one  side  is  seen 
near  the  junction  of  the  myomatous  zone  with  the 
uterine  muscle.  The  large  clear  spaces  scattered 
throughout  the  myomatous  zone  are  dilated  glands.  Here  and  there  a  dark  patch  is  seen  in 
which  no  glands  are  present.  Islands  of  stroma  devoid  of  glands  also  occur.  The  glandular 
elements  diminish  in  number  in  the  outer  portions  of  the  growth  and  at  the  point  where  the 
uterine  muscle  commences  they  are  absent.  The  outer  zone  consisting  of  uterine  muscle  presents 
the  appearance  of  normal  muscle. 


DIFFUSE    A.DENOMYOB1A    OF   THE    [JTERU8  79 

The  uterine  cavity  is  7.5  cm.  in  Length,  and  al  the  upper  pari  s  cm. 
in  breadth.  T  he  mucous  m  e  m  b  r  a  n  e  of  1  h  e  a  n  - 
terior  uterine  wall  varies  from  7  to  8  mm.  in 
thickness,  is  yellowish-white  in  color,  smooth  and  glistening. 
In  many  places,  however,  it  presents  ecchymoses  in  the  superficial 
portions.  In  the  vicinity  of  the  internal  os  and  extending  upward 
for  about  2.5  cm.  are  three  or  four  longitudinal  folds  of  the  mucosa. 
The  depressions  between  these  are  about  4  or  5  mm.  in  depth.  The 
mucosa  covering  the  posterior  wall  varies  from  3  to  4  mm.  in  thick- 
ness. 

Right  side:  The  tube  is  11  cm.  long,  and  averages  7  mm.  in 
diameter.  Its  fimbriated  extremity  is  patent;  the  parovarium  is 
intact.  The  ovary  measures  8  by  2.5  by  1.5  cm.,  is  pale  white  in 
color,  smooth  and  glistening.  It  contains  two  corpora  lutea,  the 
larger  of  which  is  2.5  cm.  in  diameter. 

Left  side:  The  tube  is  9  cm.  long  and  6  mm.  in  diameter.  Its 
extremity  is  patent;  the  parovarium  is  intact.  The  ovary  measures 
4  by  4  by  1  cm.,  is  yellowish-white  in  color  and  somewhat  lobulated. 
It  contains  a  cyst  2.5  cm.  in  diameter.  The  walls  of  this  are  2  mm. 
in  thickness  and  the  inner  surface  is  dirty  brown  in  color. 

Histological  Examination  .—The  nodule  project- 
ing into  the  uterine  canal  is  composed  of  non-striped  muscle  fibres. 
Its  outer  surface  is  in  places  covered  with  cylindrical  epithelium,  but 
in  most  places  apparently  with  several  layers  of  spindle-shaped 
connective-tissue-like  cells.  Scattered  everywhere  throughout  this 
muscle  are  gland-like  spaces  varying  from  a  pin-point  to  3  mm.  in 
diameter.  These  are  lined  with  one  layer  of  epithelium,  which  in  the 
smaller  glands  is  of  a  high  cylindrical  variety.  In  the  dilated  glands, 
however,  it  is  cuboidal,  or  has  become  almost  flat.  The  protoplasm 
of  the  cells  takes  the  hematoxylin  stain.  The  nuclei  are  oval  and 
vesicular,  and  in  many  places  it  is  possible  to  make  out  the  cilia. 
The  glands  are  empty  or  contain  a  granular  material  that  takes  the 
hematoxylin  stain.  These  glands  resemble  to  some  extent  those  of 
the  cervix. 

The  surface  of  the  mucosa  covering  the  anterior  uterine  wall 


80  ADENOMYOMA   OF   THE    UTERUS 

presents  in  places  a  wavy  outline  (Fig.  24).  Its  epithelium  is  of  the 
high  cylindrical  variety  and  is  everywhere  intact.  In  a  few  places 
it  is  swollen  and  somewhat  flattened.  The  glands  are  moderate  in 
number,  are  small  and  round  on  cross-section,  and  have  an  intact 
epithelium.  A  few  of  them  are  slightly  dilated  and  contain  desqua- 
mated epithelium.  The  glands  may  be  traced  for 
from  7  to  10  mm.  before  any  muscular  sub- 
stance is  encountered;  they  then  end  abrupt- 
ly   or    continue    into    the    muscle,    where    they 


Fig.  25. — Cross-section  of  a  gland  taken  from  Fig.  24  at  d.     (150  diameters.) 

The  gland  is  lined  with  one  layer  of  cylindrical  epithelium  and  is  surrounded  by  cells  having 
oval  vesicular  nuclei.  Its  appearance  is  identical  with  that  of  the  normal  uterine  gland.  Sur- 
rounding the  stroma  of  the  gland  are  non-striped  muscle  fibres,  the  majority  of  which  are  cut 
longitudinally. 

can  in  places  be  traced  for  at  least  1  cm.; 
this  down-growth  is  visible  in  many  places. 
The  stroma  of  the  mucosa  is  composed  of  cells  whose  nuclei  vary 
from  the  oval  vesicular  type,  as  seen  near  the  surface,  to  deeply 
staining  ones,  as  noticed  in  the  depth  of  the  mucosa.  In  some 
places  the  stroma  cells  have  elongate  oval  nuclei;  so  that  it  is  im- 
possible to  distinguish  them  from  muscle  fibres.  The  superficial 
portions  of  the  stroma  show  marked  signs  of  hemorrhage,  which  is 
localized  to  certain  areas.  The  stroma  as  a  whole  does  not  appear 
to  be  very  vascular. 


DIFFUSE    A  MYXOMYOMA    OF    THE    UTERUS 


81 


The  thickened  and  striated  portion  of  the  anterior  uterine  wall 
is  composed  of  non-stripod  muscle  fibres,  which  are  for  the  most 
pari  cul  Longitudinally.  The  fibres  run  in  all  directions,  are  closely 
packed  together,  but  only  in  n  few  places  are  concentrically  arranged. 

Scattered  throughout    this  tissue  are  numerous  cell-  having  small, 
round,   deeply   staining  nuclei   which   resemble  those  of   Lymphoid 

b      b'    tf 


e  e  4 

Fig.  26. — A  branching  gland  from  a  glandular  area  in  an  adenomyoma.      (85  diameters.) 

Gyn.-Path.  No.  497.  The  section  is  taken  from  the  diffuse  growth  in  the  anterior 
uterine  wall  in  Fig.  '_':•>.  a  appears  to  be  the  main  trunk  of  the  gland.  Upward  we  have  three 
branches  b,  /<'.  /<",  downward  it  can  be  traced  to  d  and  to  the  right  as  far  as  c.  The  gland  with 
its  various  branches  appears  to  be  lined  with  numerous  layers  of  cells.  This  is  due  to  the  thick- 
ness of  the  section.  It  is  in  reality  lined  with  a  single  layer.  There  is  nothing  in  the  leas!  sug- 
gestive of  malignancy.  At  points  e  are  sections  of  other  glands.  The  gland  f  IS  cul  on  the  bevel 
at  /'.  The  stroma  surrounding  the  glands  is  exceptionally  dense  owing  to  the  unusual  number  of 
st  roina  cells. 

cells.     Under  the  microscope  it  is  impossible  to  tell  where  the  coarsely 

thickened  zone  ends  and    the   normal    uterine   muscle  commences, 

the  transition  of  the  one  into  the  other  being  so  gradual.     Traversing 

this  thickened  portion  of  the  uterine  wall  are  small  clusters  of  glands, 

precisely  similar  to  those  of  the  uterine  mucosa   (Fig.  24).     These 

glands  are  round  or  oval  and  are  lined  with  one  layer  of  cylindrical 
6 


82  ADENOMYOMA   OF   THE   UTERUS 

ciliated  epithelium.  A  few  longitudinal  sections  of  the  glands  are 
here  and  there  visible.  Some  of  the  glands  are  dilated,  one  of  them 
reaching  5  mm.  in  diameter.  The  epithelium  of  the  dilated  glands 
is  in  places  somewhat  flattened  or  has  entirely  disappeared. 

In  one  place  two  glands  are  seen  opening  into  a  dilated  gland. 
Nearly  all  of  the  glands  are  surrounded  by  stroma  similar  to  that  of 
the  uterine  mucosa  (Fig.  25).  A  small  isolated  gland  is  occasionally 
found  lying  directly  between  the  muscle  fibres,  and  a  few  of  the 
cysts  have  no  stroma  surrounding  them.  The  invasion  by 
the  glands  can  be  traced  to  the  point  at  which 
the  coarsely  striated  tissue  joins  the  uterine 
muscle.  They  are  most  abundant  near  the  uterine  mucosa  and 
gradually  diminish  as  one  passes  outward.  They  may  be  scattered 
anywhere  throughout  the  myomatous  growth,  but  appear  for  the 
most  part  to  occupy  the  spaces  between  the  muscle  bundles.  In  only 
a  few  places  can  any  concentric  arrangement  of  muscle  fibres  be  made 
out  around  the  glands.  The  glands  themselves  show  no  evidence  of 
degeneration. 

From  the  above  it  will  be  seen  that  there  is  a  diffuse  muscle 
thickening  of  the  anterior  uterine  wall,  and  that  there  is  a  down- 
growth  of  normal  uterine  glands  into  the  newly  formed  muscle. 
Along  the  lower  margin  of  the  growth  is  a  typical  myomatous  nodule 
5  mm.  in  diameter. 

The  mucosa  covering  the  posterior  wall  is  normal. 

The  right  tube  and  ovary  are  normal. 

The  left  tube  is  normal.  The  small  cyst  of  the  left  ovary  has  no 
epithelial  lining,  hence  its  exact  origin  cannot  be  ascertained. 

Gyn.  No.  12,807.  Path.  No.  9699. 
Diffuse  adenomyoma  of  the  anterior  wall 
w  J  th  commencing  adenomyoma  of  the  pos- 
terior wall.  Gland  elements  derived  from  the 
uterine  mucosa;  a  few  discrete  myomata; 
general  pelvic  adhesions;  s m a  1 1  G r a  a f i a n  f o 1 - 
licle    cyst    on    the    right    side. 


DIFFUSE    A.DENOMYOMA    OF   THE    UTERUS  s-'l 

A.,  colored,  A pii  1   11,   L906.     Operation:    Hysterectomy;    right 

salpingo-oophoro-cystectomy ;  lot* i   salpingo-oophorectomy. 

The  specimen  consists  of  the  uterus  which  has  beeu  amputated 
through  the  cervix.  It  measures  7  by  7  by  6  cm.  and  is  everywhere 
covered  with  adhesions,  .hist  posterior  to  the  utero-ovarian  liga- 
ment is  a  myoma  1">  cm.  in  diameter.  The  .-interior  uterine  wall  is 
dense  and  varies  from  1.5  to  2.5  cm.  in  thickness.  The  posterior 
wall  is  also  dense  and  slightly  thicker.  In  the  fundus  is  a  myoma 
somewhat  diffuse  in  character,  1.5  cm.  in  diameter.  The  uterine 
mucosa  is  very  thin. 

The  right  tube  is  bound  down  by  adhesions,  but  its  fimbriated 
end  is  patent.  The  right  ovary  is  converted  into  a  cyst  approxi- 
mately 6  cm.  in  diameter.     This  is  likewise  covered  with  adhesion-. 

Sections  from  the  anterior  uterine  wall  show  that  the  surface  is 
ragged,  suggesting  that  the  curette  has  previously  been  used.  The 
mucosa  is  dense  and  the  glands  are  flattened  and  several  are  running 
at  right  angles  to  the  surface.  The  stroma  of  the  mucosa  is  appa- 
rently normal.  Just  beneath  the  mucosa  the  tissue  is  definitely  myo- 
matous, being  divided  up  into  large  and  small  bundles,  and  between 
these  are  isolated  glands.  In  some  places  the  mucosa 
c  a  n  be  traced  down  into  this  m  yomatous  tis- 
sue, and  cross-sections  of  isolated  glands  accompanied  by  stroma 
can  be  seen  at  least  1  cm.  from  the  mucosa.  In  the  posterior  wall 
the  mucosa  presents  essentially  the  same  picture  as  in  the  anterior. 
There  is,  however,  little  tendency  for  the  mucosa  to  extend  into  the 
depth,  except  here  and  there,  where  isolated  glands  project  down 
into  the  myomatous  muscle. 

We  have  here  a  definite  adenomyomatous  thickening  of  the 
posterior  wall  with  commencing  adenomyoma;  dense  adhesions 
covering  the  uterus;  a  few  discrete  myomata  and  general  pelvic 
adhesions  with  a  small  Graafian  follicle  cyst  on  the  right  side. 

Gyn.  No.  12,841.     Path.  No.  9744. 
Subperitoneal,      interstitial,      and      submu- 
cous    uterine     m  v  o  m  a  t  a  .     Co  m  m  e  n  c  i  n  g     a  d  e  n  0  - 


84  ADENOMYOMA   OF  THE   UTERUS 

myoma;     general     pelvic     adhesions;     old     sal- 
pingitis. 

A.  R.,  single,  aged  forty-three,  white.  Admitted  April  13,  1906; 
discharged  May  17,  1906.  The  patient  entered  the  hospital  com- 
plaining of  a  tumor  of  the  uterus  and  irregular  menstruation.  Her 
menses  commenced  at  fifteen,  were  regular,  lasting  from  two  to 
three  days.  For  the  past  year  they  have  been  somewhat  irregular 
and  were  prolonged  a  day  or  two  longer  than  usual,  associated  with 
some  pelvic  discomfort,  and  pain  in  the  leg.  For  the  last  two  or 
three  years  she  has  had  some  slight  leucorrhcea.  Urination  was 
somewhat  frequent  and  there  was  dysuria  for  a  time  five  or  six 
months  ago.  At  that  time  it  was  necessary  to  catheterize  the 
patient.  Three  and  a  half  years  ago  the  patient  had  a  slight  uterine 
prolapsus.  About  seven  months  ago  she  had  what  was  said  to 
have  been  "  inflammation  of  the  bowels"  lasting  some  weeks. 

Operation  . — On  entering  the  abdomen  it  was  found  that 
the  bladder  extended  half-way  to  the  umbilicus  and  the  pelvic 
tumor  was  so  adherent  that  its  release  was  exceedingly  difficult. 
During  the  manipulation  a  tear  was  made  in  the  outer  coat  of  the 
rectum.  The  tear  was  2\  inches  long  and  about  \\  inches  broad. 
The  surfaces  were  brought  together  with  fine  black  silk.  The 
highest  post-operative  temperature  was  101.5°  F.,  on  the  third  day. 
The  patient  made  a  satisfactory  recovery  and  was  discharged  on 
May  17,  1906. 

Path.  No.  9744  . — The  specimen  consists  of  a  myoma- 
tous uterus,  8  by  8  by  5  cm.  Projecting  from  the  anterior  surface 
is  a  pedunculated  nodule  3  cm.  in  diameter  and  another  1  cm.  in 
diameter.  Scattered  throughout  the  uterine  walls  are  several 
myomatous  nodules,  the  largest  being  about  3  cm.  in  diameter. 
Attached  to  the  posterior  surface  of  the  uterus  over  almost  its  entire 
extent  is  an  irregularly  lobulated  tumor,  17  by  12  by  12  cm.  It  is 
covered  with  dense  adhesions  and  on  the  surface  is  apparently  be- 
coming necrotic.  The  uterine  walls  average  about  2  cm.  in  thick- 
ness.    The  mucosa  has  not  been  well  preserved. 

Sections  from  the  mucosa  show  that  the  surface  epithelium  is 


DIFFUSE   ADENOMYOMA    OF   THE    I  TER1  -  s" 

intact.  There  is  a  moderate  amount  of  gland  hypertrophy  and  also 
some  polypoid  formation.  The  mucosa  shows  a  distinct  tendency 
to  project  into  the  depth.  We  have  at  one  point  an  area  thai  stains 
sharply  with  eosin  and  which  mighl  very  readily  be  mi-taken  for 

an  area  of  necrosis  or  for  a  recent  tubercle.  Examination  with  the 
Midi  power  shows  no  resemblance  to  tuberculosis. 

A  section  from  one  of  the  myomata  shows  a  great  deal  of  hyaline 
degeneration  and  commencing  liquefaction.  The  tube  shows  evi- 
dence of  chronic  inflammation. 

Diagnosis  . — Subperitoneal,  interstitial,  and  submucous 
uterine  myomata;  a  practically  normal  uterine  mucosa  with  a  dis- 
tinct tendency  to  penetrate  into  the  depth;  general  pelvic  adhesion- : 
old  salpingitis. 

Gyn.  No.  9788.     Path.  No.  6008. 

Diffuse  adenomyoma  of  the  anterior  w  a  1  1 
and  fundus  and  diffuse  thickening  of  the  pos- 
terior wall  with  but  little  tendency  for  the 
g  lands    to    invade     the    muscle. 

E.  S.,  aged  thirty-two,  white,  married.  Complaint:  "Bearing- 
down"  in  the  lower  abdomen  and  uterine  hemorrhage.  The  menses 
began  at  fifteen,  were  regular,  lasting  from  five  to  six  days,  but  not 
profuse.  The  patient  had  some  pain  with  her  periods  until  after 
the  birth  of  her  child  seven  years  ago.  Since  December.  1900,  she 
has  had  several  severe  hemorrhages  at  the  time  of  her  periods. 
She  has  been  married  eight  years,  has  had  one  child,  but  no  mis- 
carriages. Profuse  leucorrhcea  has  been  present  for  the  last  year. 
In  December,  1900,  the  patient  had  a  severe  hemorrhage  which 
started  at  the  time  of  the  regular  period  and  lasted  for  six  weeks. 
She  was  in  bed  for  four  weeks  after  this.  She  had  slight  hemorrhage 
;it  the  time  of  the  period  in  February.  1902.  when  for  a  week  she  had 
a  very  profuse  flooding,  but  not  so  severe  as  the  firsl  time.  Since 
February  the  patient  has  had  almost  constant  but  very  slight  bleed- 
ing. This  is  apparently  brought  on  by  exertion.  For  two  or  three 
weeks  the  patient  has  had  a  good  deal  of  bearing-down  pain,  which 


86  ADENOMYOMA   OF   THE    UTERUS 

is  partially  relieved  by  lying  down.  She  is  in  a  good  condition,  but 
shows  slight  pallor  of  the  mucous  membranes. 

Operation  . — Hy stero-myomectomy ;  left  salpingo-oophor- 
ectomy;  right  salpingectomy.  The  patient  made  an  uninterrupted 
recovery. 

Path.  No.  6008  . — The  uterus  has  been  amputated  through 
the  cervix.  It  is  9  cm.  in  length  and  nearly  9  cm.  in  breadth.  The 
uterine  mucosa  has  been  almost  entirely  curetted  away,  but  near 
the  right  cornu  some  of  the  thickened  mucosa  still  remains.  The 
uterine  walls,  both  anteriorly  and  posteriorly,  show  diffuse  myo- 
matous thickening.     They  vary  from  3.5  to  4.5  cm.  in  thickness. 

The  appendages  are  normal. 

On  histological  examination  the  uterine  glands  show  some  hyper- 
trophy. The  diffuse  growth  in  the  anterior  wall 
has  everywhere  been  invaded  by  islands  of 
uterine  mucosa.  The  glands  composing  these  are  for  the 
most  part  normal,  but  in  some  places  there  is  moderate  dilatation. 
The  uterine  mucosa  can  be  seen  extending 
down  in  large  quantities  into  this  diffuse 
growth,  and  there  is  no  doubt  that  the  gland  elements  are 
derivatives  from  those  of  the  mucosa. 

Sections  from  the  fundus  and  from  the  upper  part  of  the  pos- 
terior wall  also  show  infiltration  with  islands  of  mucosa.  In  the 
lower  part  of  the  posterior  wall  is  a  diffuse  thickening,  but  there  is 
little  tendency  for  the  glands  to  penetrate  into  the  depth. 

Gyn.  No.  10,519.     Path.  No.  6754. 

Diffuse  adenomyoma  of  the  uterus,  the 
glands  originating   from  the  mucosa. 

S.  R.,  single,  aged  forty-nine,  white.  Admitted  May  29,  1903; 
discharged  June  17,  1903.  Complaint:  Dysmenorrhcea.  Her 
menses  are  regular,  always  painful.  The  patient  had  no  bleeding 
from  October  to  December,  1902.  Then  the  periods  were  regular 
for  five  months.  For  the  last  three  months  there  has  been  a  foul 
yellowish  discharge.     At  times,  since  the  bleeding  commenced,  the 


DIFFUSE    ADENOMYOMA    OF   THE    UTERUS  87 

patienl  has  had  difficulty  in  holding  her  urine.     For  the  last   three 
years  the  pains  at  the  periods  have  been  much  worse,  nol  only  in 
the  back  but  in  both  legs  and  groins.     Haemoglobin  50  percent. 
Opera  tion.     Hystero-salpingo-oophorectomy.     The  patienl 

made  a  satisfactory  recovery  and  was  discharged  on  the  twentieth 
day. 

Path.  No.  6754  . — The  specimen  consists  of  a  very  evenly 
enlarged  uterus  with  the  tubes  and  ovaries  attached.  The  uterus 
is  rather  dense  and  hard.  It  measures  7.5  cm.  in  lenuth,  1  cm.  in 
breadth.  The  uterine  mucosa  in  places  presents  a  polypoid  ap- 
pearance. This  is  especially  seen  in  the  vicinity  of  the  internal  os. 
The  uterine  walls  have  a  coarsely  striated  appearance  and  there  are 
little  openings,  suggesting  the  gland-like  spaces  of  an  adenomyoma. 
The  thickening  is  uniform  in  both  the  anterior  and  posterior  walls. 

The  tubes  and  ovaries  appear  normal. 

Histological  Examination  . — Sections  from  the 
body  of  the  uterus  showr  that  the  mucosa  is  perfectly  normal,  that 
it  is  much  thickened,  and  in  numerous  places  there  is  a  tendency  for 
the  mucosa  to  penetrate  into  the  depth.  In  the  inner  zone  of  the 
uterus,  where  the  diffuse  thickening  is  noted,  the  tissue  is 
myomatous,  and  scattered  throughout  this 
are  i  s  1  a  n  d  s  of  uterine  m  u  c  o  s  a  similar  to  those  found 
in  an  adenomyoma.  One  cm.  from  the  outer  surface  of  the  uterus 
is  a  miniature  cavity  4  mm.  in  diameter.  At  other  points  there  are 
dilated  glands  filled  with  old  hemorrhage.  There  is  no  doubt  that 
the  glands  in  this  case  have  originated  from  the  mucosa. 

Diagnosis. — Diffuse  adenomyoma  of  the  anterior  and 
posterior  uterine  walls;   normal  appendages. 


CHAPTER  IV 

CASES  OF  ADENOMYOMA  IN  WHICH  THE  UTERUS  RETAINS  A  RELA- 
TIVELY NORMAL  CONTOUR—  (Continued) 

Gyn.  No.  7569.     Path.  No.  3903. 

Diffuse  a  d  e  n  o  my  o  m  a  of  the  anterior  and 
posterior  uterine  walls,  most  pronounced  in 
the    fundus    and    posterior    wall  (Figs.  27,  28,  and  29) . 

L.  C,  married,  white,  aged  forty-six.  Admitted  February  12, 
discharged  April  26,  1900.  The  patient  complained  of  discharge 
of  urine  through  the  vagina  and  of  incontinence  of  feces.  Her 
mother,  who  died  of  leprosy  at  the  age  of  forty-seven,  had  two  chil- 
dren while  suffering  from  this  disease.     Both  are  living  and  well. 

When  the  patient  was  twelve  years  of  age  she  had  rheumatism, 
and  since  that  time  has  complained  of  shortness  of  breath.  At 
twenty  years  of  age  she  had  a  second-attack  of  rheumatism. 

Her  menses  commenced  at  sixteen,  were  regular  every  four  weeks, 
lasting  four  days.  The  flow,  however,  was  accompanied  by  pain 
and  she  had  to  remain  in  bed  for  two  days.  The  flow  has  always 
been  profuse.  For  the  last  two  years  the  menstrual  periods  have 
been  painful  and  irregular ;  sometimes  an  interval  of  two  months  will 
elapse.  There  has  been  no  change  in  the  character  of  the  flow.  Her 
last  period  came  on  on  December  24,  1899.  The  previous  period 
had  occurred  two  months  before. 

The  patient  was  married  at  nineteen  and  had  two  children,  both 
stillborn,  no  miscarriages.  She  had  convulsions  at  the  onset  of  the 
first  labor  twenty-five  years  ago  and  was  badly  torn.  At  the  second 
labor,  twenty-three  years  ago,  there  was  a  complete  tear  in  which  the 
bladder  was  implicated.  Ever  since  the  birth  of  her  first  child  the 
patient  has  been  suffering  from  incontinence  of  feces.  The  condition 
was  not  improved  after  the  birth  of  the  second  child.  At  that  time 
a  vesicovaginal  fistula  developed.     Nineteen  years  ago  the  patient 


DIFFUSE    ADENOMYOMA    OF   THE    UTERI  -  89 

was  operated  upon  and  an  at  tempi  was  made  to  close  I  be  fisl  ula  with 
silver  wire.  A  second  attempt  was  made  two  years  later,  but  both 
were  unsuccessful. 

Following  the  birth  of  the  second  child  the  patient  had  phlebitis 
of  the  left  leg.  The  leg  has  since  been  more  or  less  swollen  and  al 
times  painful. 

Apart  from  a  presystolic  murmur  at  the  apex  of  the  heart  the 
thorax  is  clear.  Both  labia  minora  and  majora  are  inflamed,  ap- 
parently owing  to  the  escape  of  urine.  Protruding  from  the  vagina 
is  what  appears  to  be  a  rectocele.  The  perineum  shows  a  complete 
tear  extending  4  or  5  cm.  into  the  rectovaginal  septum.  The  mucosa 
over  the  rectum  protrudes  slightly  and  is  very  red  in  appearance. 
In  the  upper  part  of  the  anterior  wall,  about  1  cm.  from  the  cervix, 
is  a  scar  which  extends  across  the  vagina,  and  at  the  left  angle  of 
the  scar  is  a  vesicovaginal  fistula.  The  cervix  is  deeply  lacerated. 
The  external  os  is  patulous. 

February  14th.  Aniline  solution  and  methylene-blue  were  used 
to  determine  the  condition  of  the  ureters  and  the  relation  of  the 
fistula  to  the  left  ureter  and  the  bladder. 

Diagnosis :  A  left  ureteral  fistula  into  the  vagina  and  a  vesico- 
vaginal fistula ;   also  a  rupture  of  the  rectovaginal  septum. 

February  19th.  The  ureter  was  cut  around  on  all  sides  and 
turned  into  the  bladder.     The  rectovaginal  septum  was  restored. 

March  11th.  The  stitches  were  removed  from  the  vesicovaginal 
fistula.  They  were  covered  with  incrustations.  An  area  of  granu- 
lation 4  cm.  long  was  found  with  urine  escaping  from  it.  The  site 
of  operation  for  complete  tear  was  entirely  separated  except  for  the 
two  triangular  areas  in  the  vagina. 

An  opening  was  now  made  into  the  peritoneal  cavity.  The 
uterus  was  found  to  be  myomatous  and  the  tubes  and  ovaries  were 
adherent.  The  uterus,  the  left  tube  and  left  ovary  were  removed 
in  the  usual  way.  The  ureter  was  then  turned  into  the  bladder  and 
the  vesicovaginal  fistula  repaired. 

Convalescence  was  slow  and   the  patient  complained  of  much 


90 


ADENOMYOMA   OF   THE    UTERUS 


vomiting. 


There  was   con- 


•  • 


v 


discomfort,   especially   of  nausea   and 
siderable  vaginal  pain. 

March  30th.     She  had  a  chill,  the  temperature  rising  to  102.8°  F. 
On  April  6th  she  developed  phlebitis  in  the  right  leg. 

April  24th.  The  fistulous 
tract  in  the  abdominal  incision 
appears  to  have  entirely  closed. 
The  perineum  is  in  the  same 
condition  as  at  the  time  of  ad- 
mission. The  uretero vaginal 
fistula  appears  to  have  been 
converted  into  a  vesicovaginal 
fistula.  The  patient  was  dis- 
charged on  April  26th. 

Gyn.-Path.  No. 
3  9  0  3  . — The  specimen  con- 
sists of  the  uterus  with  its  left 
appendages.  The  uterus,  which 
has  been  amputated  at  the  cer- 
vix, is  8  cm.  in  length,  6.5  cm. 
in  breadth,  and  5.5  cm.  in 
its  antero-posterior  diameter. 
The  anterior  surface  is  smooth 
and  glistening.  The  posterior 
aspect  is  covered  with  a  few 
adhesions.  At  the  fundus  is  a 
slightly  rounded  boss,  3  cm.  in 
diameter.  The  uterine  cavity 
is  2.5  cm.  in  length  and  at 
the  fundus  3.5  cm.  in  breadth. 
The  anterior  uterine  wall  averages  2.5  cm.  in  thickness  and  in 
its  inner  portion  is  slightly  coarse  in  texture.  The  posterior 
wall  varies  from  2.5  to  3.5  cm.  in  thickness  and  from  the 
peritoneal  surface  to  the  mucosa  is  coarsely  striated,  resembling- 
diffuse  mvomatous  tissue  (Fig.  27).     Scattered    through- 


a.  a 

Fig.  27. — Diffuse  adenomyoma  of  the  body 
of  the  uterus.     (Natural  size.) 

Gyn.-Path.  No.  3903.  The  uterus 
has  been  amputated  through  the  cervix.  Occupy- 
ing nearly  the  entire  body  of  the  organ  is  a  diffuse 
myomatous  growth.  In  the  upper  part  all  trace 
of  the  normal  muscle  has  disappeared  except  at  b. 
Downward  the  growth  can  be  traced  to  a  and  a'. 
The  myomatous  portion  is  composed  of  coarse 
bands  of  tissue  passing  in  all  directions  and  often 
forming  definite  whorls  with  small  round  or 
irregular  cavities  in  their  centres.  Some  of  these 
cavities  are  cross-sections  of  blood-vessels;  others 
are  small  cysts.  The  portion  of  the  uterine  cavity 
seen  presents  the  normal  appearance  and  the  mu- 
cosa shows  no  change.  For  the  histological  pic- 
ture see  Figs.  28  and  29. 


DIFFUSE    A  MYXOMYOMA    OF    THE    I  TER1  - 


.»! 


o  u  I  I  li  i  s  c  o  a  r  a  e  I  i  s  a  u  e  a  r  e  a  m  a  II  cyst-lik  e 
spaces,  a  o  m  e  reaching  I  mm.  in  diameter. 
\'<>  definite  myomatous  foci  can  be  found. 

The  left  tube  and  ovary  are  covered  with  adhesions. 

II  is  t  olo  g  i  c  a  1  E  x  a  m  i  n  a  t  ion  . — The  uterine  mucosa 
liasan  intact  surface  epithelium  which  in  some  places  is  considerably 


B*| 


u 


&  S5  /'  . 


-'.:S"'i.\"'*-''f  ?■''/'■ 


4&E3P 


-,f 


-ft    ^     ,."..,. 


e  a 

I^ic.  28. — Extension  of  the  Ihucosa  into  the  muscle  in  a  cask  of  diffuse  adenomyoma 

of  the  I'TKKis.     (50  diameters.) 

Gy  n.  -Path.   No.   3  !)(»:}.     The  section  is  from  the  body  of  the  uterus  in  Fig.  _'7. 
a  represents  the  thickness  of  the  mucosa  which  is  smooth  save  for  t  lie  slight  projection  b.     The 

uterine  glands  are  normal  in  appearance  and  t  he  st  roma  is  dense,  resembling  t  hat  normally  found 
after  the  menopause.     The  mucous  membrane  is  extending  en  massi  into  the  myomatous  tissue 

and  can  lie  followed  as  far  as  c.  <l  is  a  small  tuft  n\'  myomatous  muscle  almosl  Completely  en- 
circled by  mucosa,  e  is  an  isolated  gland  ill  the  muscle  and  partially  surrounded  by  the  char- 
acteristic stroma.     /  is  a  vein. 


flattened.  The  mucosa  is  thin  and  its  glands  are  very  small,  re- 
sembling those  seen  after  the  menopause.  The  gland  epithelium 
is  everywhere  intact  and  normal.  The  stroma  of  the  mucosa,  as 
in  old  individuals,  is  very  dense.  The  coarse  and  striated  appearance 
of  both  uterine  walls,  more  particularly  of  the  posterior,  is  due  to 
an  almost  complete  myomatous  transformation  of  the  uterine  muscle. 
As  a  matter  of  fact,  in  the  posterior  wall  this  diffuse  myomatous 


92 


ADENOMYOMA  OF  THE    UTERUS 


condition  can  be  followed  to  the  peritoneal  surface.     The   uter 


ine    mucosa    in    both    the 


a-i 


Fig.  29. — Method  of  penetration  of  a  single 
uterine  gland  into  the  diffuse  myomatous 
growth  of  an  adenomyoma.     (30  diameters.) 

Gyn.-Path.  No.  3903.  The  section 
is  from  the  body  of  the  uterus  seen  in  Fig.  27;  in  the 
upper  part  of  the  field  is  the  uterine  mucosa,  the 
lower  limits  of  which  are  represented  by  a.  The 
glands  present  the  normal  appearance,  but  the 
stroma  around  some  of  them  is  pale-staining,  while 
that  in  the  vicinity  is  denser  than  usual.  There  is, 
however,  no  evidence  of  inflammation.  At  b  are 
cross-sections  of  two  small  glands.  The  origin  of 
such  glands  is  indicated  by  c,  where  we  have  a 
longitudinal  section  of  one  commencing  in  the  mu- 
cosa and  penetrating  the  myomatous  muscle.  It  is 
lost  for  a  space,  but  again  recognized  at  c'.  Near 
the  mucosa  it  seems  devoid  of  stroma,  but  in  the 
deeper  portions  it  is  partially  surrounded  by  stro- 
ma,    d  is  a  vein. 


anterior  and  poste- 
rior walls  dips  down 
at  many  points  into 
this  myomatous  tis- 
sue (Fig.  28).  In  the  an- 
terior wall  it  is  possible  to 
trace  an  individual  gland  3 
mm.  into  the  depth  (Fig.  29). 
In  the  posterior  wall  a  similar 
extension  of  the  mucosa  into 
the  myomatous  tissue  is 
demonstrable,  and  scattered 
everywhere  throughout  the 
posterior  wall,  but  more  par- 
ticularly at  the  fundus  and 
extending  almost  to 
the  peritoneal  sur- 
face, are  islands  of 
s  membrane, 
particular  case  they 
are  very  small,  individual 
islands  rarely  containing  more 
than  two  glands  with  their 
surrounding  stroma.  These 
glands  resemble  typical  uter- 
ine glands  and  their  stroma  is 
identical  with  that  of  the  mu- 
cosa. Some  of  the  glands  are 
dilated  and  irregular,  and 
form  the  cyst-like  spaces  noted 
macroscopically.  Where  the 
glands  are  moderately  dilated 
their  epithelium  frequently 
stains  quite  palely.    Occasion- 


DIFFUSE    ADENOMYOMA    OF   THE    I  TER1  -  93 

ally  an  island  of  stroma  is  found  devoid  of  gland  elements,  and  now 
and  then  a  small  gland  is  seen  devoid  of  stroma  and  Lying  directly 

between  muscle  bundles. 

In  this  case  we  have  ;i  diffuse  myomatous  transformation  of 
both  uterine  walls,  but  more  pronounced  in  the  posterior.  Normal 
uterine  mucosa  has  grown  into  this  diffuse  myomatous  tissue,  pro- 
ducing the  typical  picture  of  adenomyoma.  This  case  demonstrates 
very  well  the  ease  with  which  the  connection  between  the  uterine 
mucosa  and  the  glands  in  the  depth  can  be  overlooked.  We  ex- 
amined section  after  section  without  finding  this  down-growth,  but 
the  study  of  further  tissue  showed  us  the  direct  connection  between 
the  mucosa  lining  the  uterine  cavity  and  that  situated  in  the  myo- 
matous tissue. 

Diagnosis  . — Diffuse  adenomyoma  of  the  anterior  and  pos- 
terior uterine  walls  most  pronounced  in  the  fundus  and  posterior 
wall;  slight  pelvic  peritonitis. 

Gyn.  No.  2699.     Path.  No.  246. 

Interstitial  and  submucous  uterine  m  y  o  - 
m  a  t  a  ;  slight  diffuse  adenomyomatous  thick- 
ening of  the  uterine  w  all  with  the  g  lands 
originating  in  the  mucosa;  small  cyst  of  the 
o  v  a  r  y  . 

S.  L.,  married,  white,  aged  fifty.  Admitted  April  5,  1894;  dis- 
charged May  11,  1894.  Married  at  forty-eight.  She  probably  had 
a  miscarriage  several  months  after.  The  menses  appeared  at  four- 
teen, alwrays  regular,  profuse,  although  somewhat  more  so  for  the 
last  three  or  four  years.  The  patient  has  had  a  slight  leucorrhoeal 
discharge.  Eight  months  ago  a  small  tumor  was  noted  in  the  left 
lower  abdomen.  It  has  been  gradually  increasing  since  then.  She 
complains  of  weakness  and  of  backache. 

Operation. — Hystero-myomectomy.  For  the  first  forty- 
eight  hours  after  operation  she  had  almost  constant  nausea.  Her 
temperature  was  100.8°  F.  on  the  second  day.  She  made  a  satis- 
factory recovery. 


94  ADENOMYOMA   OF  THE    UTERUS 

Path.  No.  246  . — The  specimen  consists  of  the  enlarged 
uterus  with  the  tubes  and  ovaries  attached.  The  uterus  measures 
16  by  17  by  14  cm.,  is  irregular  in  outline,  smooth  and  glistening. 
Its  under  cut  surface  measures  13  by  11  by  11  cm.  Attached  to  the 
right  side  of  the  cervix  is  a  somewhat  irregular  tumor,  7  cm.  in 
diameter.  It  is  firm  and  non-yielding.  To  the  left  of  the  cervix  a 
similar  nodule  6  cm.  in  diameter  is  found,  and  the  fundus  is  occupied 
by  a  tumor,  10  cm.  in  diameter. 

The  cut  surface  of  this  tumor  presents  a  somewhat  striated  ap- 
pearance. It  is  pearly  white  in  color  and  very  hard  in  consistency. 
The  other  nodules  are  similar  in  character  and  all  of  them  are  covered 
with  a  layer  of  muscle  about  2  mm.  in  thickness.  Scattered  through- 
out the  uterine  walls  are  other  smaller  and  similar  nodules,  while 
projecting  into  the  uterine  cavity  is  a  tumor  mass,  7  cm.  in  diameter. 
The  uterine  cavity  is  6  cm.  in  length.  Its  mucosa  averages  1  mm. 
in  thickness;  it  is  pale  and  glistening.  Over  the  submucous  nodules 
it  appears  atrophic.  At  the  fundus  is  a  broad  based  polyp,  1  cm. 
in  diameter.  Here  the  mucous  membrane  is  dark  red  and  in- 
jected. 

Histological  Examination  . — The  mucous  mem- 
brane over  the  large  submucous  nodule  is  somewhat  atrophic  and 
the  glands  are  moderately  dilated.  Their  epithelium  is  intact  and 
their  lumina  contain  a  pink-grayish  material.  The  stroma  is  very 
lax  and  is  made  up  of  cells  having  round  or  oval  nuclei.  The  blood- 
vessels of  the  stroma  are  very  abundant  and  in  several  places  red 
corpuscles  have  escaped  into  the  tissue.  As  one  passes  toward  the 
fundus  the  glands  in  the  depth  are  seen  to  run  parallel  with  the 
surface  instead  of  at  right  angles  to  it.  A  few  lymph-nodules  are 
found  in  the  muscular  coat  of  the  stroma.  At  the  fundus 
the  mucosa  penetrates  into  the  muscular  coat 
for  a  distance  of  3  mm.  The  glands  are  not  typical, 
but  appear  as  cavities  filled  with  epithelial  cells  and  the  muscle 
shows  a  distinct  myomatous  tendency.  All  the  nodules  scattered 
throughout  the  uterus  are  composed  of  non-striated  muscle  fibres 
cut  longitudinally  and  transversely.     There  are  areas  of  hyaline 


DIFFUSE    ADENOMYOMA    OF   THE    I  TERUS  95 

degeneration  scattered  here  and  there  throughout   the  myomatous 

1  issue. 

Both  tubes  arc  normal.  The  righl  ovary  contains  a  Graafian 
follicle  cyst  2  cm.  in  diameter.  The  left  ovary  contains  a  cysl  3.5 
cm.  in  diameter,  the  exact  nature  of  which  it  is  impossible  to  deter- 
mine. 

Diagnosis. — Interstitial  and  submucous  uterine  myomata; 
small  cysts  of  both  ovaries;  commencing  diffuse  adenomyoma. 

Gyn.  No.  12,944.     Path.  No.  9970. 

Diffuse  adeno  m  y  o  m  a  t  a  of  b  o  t  h  t  h  e  anterio  r 
and  posterior  uterine  w  alls  w  i  t  h  the  g  1  a  n  d 
elements  coming  from  the  uterine  mucosa 
(Fig.  30). 

Mrs.  B.  D.,  aged  thirty-three,  white.  Admitted  May  19.  1906; 
discharged  June  19,  1906.  The  patient  entered  complaining  of 
too  frequent  menstruation  with  pain  in  the  back  and  lower  abdo- 
men. She  has  been  a  chronic  invalid  for  ten  years.  She  had  entered 
the  hospital  on  April  13,  1904.  The  cervix  was  repaired,  the 
perineum  restored,  and  the  uterus  dilated.  She  was  discharged 
much  improved.  At  that  time  the  menses  occurred  every  two  weeks 
and  lasted  from  six  to  eight  days,  and  were  accompanied  with  severe 
pain  in  the  back  and  lower  abdomen.  Two  months  after  leaving 
the  hospital  all  the  patient's  former  symptoms  returned,  and  since 
that  time  she  has  had  her  menses  every  two  weeks,  lasting  from 
ten  to  twelve  days,  and  accompanied  by  severe  pain  in  the  back 
and  lower  abdomen.  She  passes  large  clots  at  times  and  the  flow 
is  very  excessive.  The  patient  is  incapacitated  on  account  of  the 
pain  and  profuse  flow,  which  weakens  her  greatly.  She  has  numer- 
ous varicose  veins  about  the  ankles  and  the  legs  swell  at  times. 

There  is  much  adipose  tissue  in  the  abdomen:  some  increase  in 
resistance  in  the  median  line.  The  outlet  is  moderately  relaxed: 
the  cervix  is  low;  the  fundus  is  slightly  irregular  in  outline,  enlarge*  1. 
about  the  size  of  a  three-months  pregnancy.  There  is  no  tenderness 
laterally.     The   uterus   was   removed   in   the   usual   way.     The   ap- 


96 


ADENOMYOMA   OF   THE    UTERUS 


pendix,  which  was  partially  obliterated  over  its  base,  was  also  re- 
moved. The  patient  made  a  satisfactory  recovery.  The  highest 
temperature  was  101°  F.,  twenty-four  hours  after  the  operation. 


"^x. 


•■•„■  ■  -  . .  ..:       .■,■  ■ :-   ■■.-.-■*■■:    ; 


.Cm..    . 


;■<:?.©■ 


<!.- 


...Si 


•"^j  if  /' 


<X.    TCr^^s. 


r^# 
^%-^r 


Fig.  30. — Diffuse  adenomyoma  of  the  body  of  the  uterus.     (6  diameters.) 

Gyn.-Path.  No.  9970.  The  section  embraces  the  upper  part  of  the  uterine  cavity. 
a  and  b  indicate  the  relatively  normal  thickness  of  the  mucosa.  The  ragged  inner  surface  is  due  to 
a  recent  curettage.  The  mucosa  is  everywhere  much  thickened  and  is  extending  into  the  under- 
lying myomatous  muscle.  This  down-growth  is  strikingly  well  seen  at  c,  and  is  also  extensive  at 
d,  e,  and  /.  At  g  there  is  marked  thickening  of  the  mucosa  as  well  as  an  invasion  of  the  muscle. 
At  no  point  do  the  glands  appear  abnormal. 


Path.    No.    9970  . — The  specimen  comprises   the    uterus, 
appendages,  and  the  appendix.     The  uterus  is  approximately  twice 


DIFFUSE     \Di;\o\l  vii.\l.\    OF   THE    UTERUS  '•>/ 

the  natural  size,  measuring  9  cm.  in  length,  (.i  cm.  in  breadth,  and  6 
cm.  in  I  hickness.  B  o  t  h  I  h  e  a  n  i  e  r  i  o  r  a  ml  p  o  s  t  e r  i  o  r 
w  alls  sh  o  w  (I  i  i'  I  u  s  e  in  y  o  in  a  I  o  u  s  I  b  i  c  k  e  □  i  n  g  , 
and  here  and  there  throughoul  the  myomatous 
areas  are  little  cyst-like  spaces.  Microscopically 
it  looks  very  much  as  if  we  are  dealing  with  an  adenomyoma. 
The  anterior  wall  varies  from  2  to  3  cm.  in  thickness.  The 
posterior  wall  also  reaches  3  cm.  in  thickness.  The  uterine 
mucosa  is  apparently  considerably  thinned  out.  being  not  over  1  mm. 
in  thickness. 

The  tubes  and  ovaries  are  apparently  normal. 

Histological  Examination  . — The  uterine  mucosa 
is  of  the  normal  thickness  and  is  rather  dense.  The  glands  present 
the  usual  appearance  and  the  underlying  muscle  shows  diffuse  myo- 
matous thickening.  The  glands  flow  down  into  the 
depth  from  both  the  anterior  and  posterior 
w  alls  (Fig.  30).  They  can  be  traced  for  a  considerable  distance. 
The  mucosa  extends  down  like  little  bays  into  the  depth.  In  some 
places  we  have  miniature  uterine  cavities.  In  the  islands  of  mucosa 
the  glands  show  a  good  deal  of  dilatation.  We  have  here,  both  in 
the  anterior  and  posterior  walls,  diffuse  adenomyoma  with  the  gland 
elements  coming  from  the  uterine  mucosa  and  diminishing  as  one 
passes  outward  toward  the  peritoneal  surface. 

Gyn.  No.  4364.     Path.  No.  1170. 

Diffuse  adenomyoma  of  the  anterior  uter- 
ine wall;  interstitial  uterine  m  y  omata;  dila- 
tation of  uterine  glands;  uterine  polypi;  very 
1  a  r  g  e  a  d  e  n  0  c  y  s  t  0  m  a  of  the  left  0  v  a  r  y  ;  g  e  n  e  r  - 
a  1  pelvic  adhesions.  H  y  s  t  e  r  e  c  t  0  m  y  a  n  d  c  y  s  t  - 
e  c  t  0  m  y  .      R  e  c  o  v  e  r  y  . 

M.  H.,  aged  fifty-nine,  white,  married.  Admitted  May  8,  1896; 
discharged  June  12.  1896.  Complaint  :  Abdominal  tumor.  The 
patient  has  had  three  children;   no  miscarriages.     The  menses  began 

at  fourteen  and  were  regular  until  ten  years  ago.     She  has  always 

7 


98  ADENOMYOMA   OF  THE    UTERUS 

had  severe  dysmenorrhea,  beginning  two  days  before  the  period 
and  lasting  until  the  flow  was  fully  established.  The  menopause 
occurred  ten  years  ago.  Two  years  ago  she  had  a  profuse  hemor- 
rhage from  the  uterus  lasting  three  days.  She  has  had  no  leucor- 
rhcea.  The  bowels  are  constipated;  micturition  is  frequent.  Oper- 
ation, May  12,  1896.  Cystectomy  and  hysterectomy.  The  ovarian 
cyst  was  intimately  adherent  to  the  surrounding  structures  and  was 
removed  with  difficulty.  The  uterus  was  then  amputated  through 
its  cervical  portion.     The  patient  made  an  uneventful  recovery. 

Gyn.-Path.  No.  1170  . — The  uterus  measures  6  by 
7  by  4  cm.  Its  surface  is  covered  with  dense  vascular  adhesions. 
The  anterior  wall  varies  from  3  to  4  cm.  in  thickness  and  is  very 
coarse  in  texture.  The  fundus  is  also  somewhat  thicker  than  usual. 
The  posterior  uterine  wall  averages  1.8  cm.  in  thickness  and  in  the 
vicinity  of  the  cervix  contains  two  interstitial  uterine  myomata  .6 
and  .5  cm.  in  diameter.  The  uterine  cavity  is  6  cm.  in  length  and  at 
the  fundus  4  cm.  in  breadth.  The  mucosa  is  smooth  and  glistening, 
but  contains  numerous  slightly  dilated  glands.  Springing  from 
the  anterior  wall  are  two  small  polypi:  the  one,  5  by  3  mm.,  also 
containing  dilated  glands;  the  other,  a  tongue-like  process,  8  mm. 
in  length  and  scarcely  1  mm.  in  thickness.  This  slender  polyp  is 
markedly  hemorrhagic,  especially  at  its  tip,  and  contains  dilated 
glands. 

Left  side :  The  Fallopian  tube  is  6  cm.  in  length,  5  mm.  in  diam- 
eter, and  covered  with  adhesions. 

The  cyst  removed  is  multilocular  and  measures  42  by  34  by  22 
cm.  It  is  pinkish  or  bluish-gray  in  color  and  covered  by  numerous 
adhesions. 

Histological  Examination  . — The  epithelium  cov- 
ering the  surface  of  the  mucosa  has  been  poorly  preserved,  but 
is  intact  and  normal.  The  mucosa  presents  a  wavy  outline  and  in 
places  is  gathered  up  into  small  polypoid  projections  or  into  definite 
polypi.  The  uterine  glands  are  fairly  abundant;  some  are  small 
and  tubular  and  frequently  present  forked  extremities,  but  many 
of  them  are  dilated,  reaching  2  mm.  or  more  in  size.     The  stroma 


DIFFUSE    AJDENOMYOMA    OF   THE    I  Ti;i;i  -  99 

is  in  some  places  denser  than  usual.  The  muscle  of  the  anterior 
uterine  wall  is  dense,  resembling  myomatous  tissue,  and  scattered 
throughoul  it  are  glands  occurring  singly  or  in  groups.  Although 
the  outer  uterine  walls  arc  considerably  mutilated,  these  glands 
can  be  traced  laterally  to  the  broad  ligamenl  attachment.  They 
arc  lined  with  one  layer  of  epithelium,  are  identical  with  uterine 
glands,  and  are  surrounded  by  a  stroma,  similar  to  thai  of  the  uterine 
mucosa.  Some  of  the  glands  are  moderately  dilated  and  at  o  n  e 
p  o  i  n  1  in  the  depth  of  the  m  u  s  c  1  e  t  h  e  r  e  i  e  a 
m  i  n  i  a  t  u  r  e  uterine  e  a  v  i  t  y  ,  there  b  e  i  n  g  s  u  r  - 
face  epithelium  1  i  n  i  n  g  the  cavity  a  n  d  n  u  m  e  r  - 
ous  glands  opening  into  it,  while  1  y  i  n  ,<:  be- 
tween the  glands  is  a  t  y  p  i  c  a  1  stro  m  a  .  A  t 
some  points  the  uterine  m  u  c  o  s  a  c  a  n  b  e  t  r  a  c  c  d 
into  the  myomatous  tissue  for  a  distance  of 
3  mm.  or  more.  The  glands  in  the  depth  evidently  arise  from 
the  uterine  mucosa.  The  uterine  muscle  shows  little  defeneration, 
but  quite  a  number  of  its  blood-vessels  are  unden>;oin<»;  obliterative 
changes,  and  some  of  them  contain  calcareous  plates  beneath  the 
intima. 

The  multilocular  ovarian  cyst  has  connective-tissue  walls  and  the 
inner  surfaces  of  the  cyst  are  lined  with  one  layer  of  high  cylindrical 
epithelium;    in  other  words,  it  presents  the  typical  appearance. 

Diagnosis. — Diffuse  adenomyoma  involving  the  anterior 
uterine  wall.  Interstitial  uterine  myomata.  Dilatation  of  the 
uterine  glands.  Uterine  polypi.  Very  la  rue  adenocystoma  of  the 
ovary.     General  pelvic  adhesions. 

Church  Home  and  Infirmary  iDr.  Hunner  .     Path.  No.  6319. 

Diffuse  a  d  e  n  o  m  y  o  m  a  o  f  t  h  e  u  t  e  r  i  n  e  w  a  1  1 
w  i  t  h    the  g  lands   c  o  m  i  n  ii-   f  r  o  m    t  h  e   m  u  c  0  s  a  . 

November  22,  1902.  The  uterus  is  considerably  enlarged.  The 
walls  reach  1.5  cm.  in  thickness.  In  some  places  the  mucosa  forms 
distinct  polypoid  outgrowths. 

Sections  from  the  endometrium  show  that  it  has  been  curetted 


100  ADENOMYOMA   OF  THE    UTERUS 

and  that  the  mucosa  presents  a  very  ragged  appearance.  Extend- 
ing down  into  the  underlying  tissue  are  uterine  glands.  These  do 
not  penetrate  singly,  but  large  areas  of  mucosa  flow  directly  into 
the  depth.  We  are  in  places  able  to  trace  the 
mucosa  by  continuity  6  mm.  into  the  depth. 
The  glands  are  perfectly  normal  except  for  here  and  there  a  dilata- 
tion. They  are  likewise  accompanied  by  normal  stroma  of  the 
mucosa.  Where  the  glands  are  dilated,  the  epithelium  sometimes 
is  pale-staining.  The  muscular  tissue  in  places  presents  the  typical 
myomatous  picture. 

Diagnosis  . — Diffuse  adenomyoma  of  the  uterus  with  the 
mucosa  flowing  directly  into  the  myomatous  tissue. 

Gyn.  No.  11,120.     Path.  No.  7351. 

Multinodular  myomatous  uterus,  the  no- 
dules being  subperitoneal  and  interstitial. 
Diffuse  adenomyoma  in  the  uterine  wall;  dis- 
crete adenomyoma  in  the  left  uterine  horn 
with  formation  of  a  miniature  uterine  cavity 
(Figs.  31  and  32). 

E.  S.,  single,  aged  fifty-one,  white.  Admitted  March  17,  1904; 
discharged  April  10,  1904.  Complaint :  Uterine  hemorrhages.  The 
patient  had  inflammatory  rheumatism  and  typhoid  fever  at  twenty- 
six.  Her  menstrual  history  has  been  normal  until  the  present  illness. 
For  two  years  the  periods  have  been  more  profuse  than  usual,  grad- 
ually increasing  until  now  she  has  very  severe  hemorrhages.  During 
the  last  year  the  periods  have  been  two  or  three  weeks  apart  and 
lasting  from  one  to  three  weeks.  She  has  lost  considerable  weight 
and  strength.     The  patient  is  well  nourished  but  looks  anaemic. 

Operation  March  21,  1904. — Hystero-myomectomy. 
Convalescence  uneventful.  The  highest  post-operative  temperature 
was  100.8°  F.,  which  was  on  the  fourth  day. 

Path.  No.  7351  . — The  specimen  consists  of  a  myomatous 
uterus  with  the  appendages  intact.  The  uterus  measures  approx- 
imately 9  by  10  by  10  cm.  (Fig.  31).     Projecting  from  the  left  uterine 


DIFFUSE    ADENOMYOMA    OF   THE    I  TER1  - 


101 


horn  is  a  subperitoneal  nodule  approximately  <*>  cm.  in  diameter. 
There  are  also  several  smaller  subperitoneal  nodule-.     Occupying 

the  anterior  wall  arc  two  myomata,  one  5  cm.  the  other  2  cm.  in 
diameter.  On  section  it  is  found  thai  the  uterine  cavity  has  beeD 
somewhat  mutilated.  The  nodule  in  the  anterior  wall  presents  the 
usual  appearance. 

The  growth  in  the  left  uterine  horn  is  sharply  circumscribed  and 


Pio.  31. — Discrete  uterine  myomata.     Diffuse  adenomyoma  with  the  glands  originating 

FROM    THE   MUCOSA.      ADENOMYOMA    OF   THE    LEFT    UTERINE    HORN.         ,'    natural    -i/.e. 

(!  y  n  .  -  1'  at  h  .  No.  7  .'i  .">  1  .     Scattered  throughout  the  uterus  are  one  medium-sized  and 
several  small  myomata.      Near  the  uterine   horn  is  a  distinct  prominence  which  on  section    - 
even  on  macroscopic  examination  to  he  a  diffuse  adenomyoma.      Histological  examination  of  the 
uterus  shows  diffuse  adenomyoma  with  the  glands  originating  from  the  mucosa,     for  a  Longitu- 
dinal section  of  t  lie  uterus  !>et  ween  points  a  and  b  see  Fig.  32. 


has  on  its  margin  two  or  three  smaller  ones.  T  h  i  s  in  y  o  m  a 
is  diffuse  in  character  a  n  d  has  scattered 
t  h  r  o  u  g  h  o  u  t  it  whitish-  y  e  1 1  o  w  p  o  r  o  u  s  a  r  e  a  s  . 
e  v  i  d  e  n  1 1  y  i  s  1  a  n  d  s  o  f  u  t  e  r  i  n  e  m  u  c  o  s  a  .  and  at  one 
point  a  cystic  dilatation  1  cm.  in  diameter  (Fig.  32),  lined  with  a 
definite  membrane  and  filled  with  a  brown  putty-like  material. 

In   the   hardened    specimen    the    uterine    mucosa    can    be    seen 


102 


ADENOMYOMA    OF    THE    UTERUS 


d  e 


macroscopically  penetrating  into  the  myoma,  the  mucosa  ex- 
tending into  the  myoma  fully  6  mm.  Surround- 
ing the  outer  surface  of  the  myoma  is  a  zone  of  normal  muscle 
varying  from  3  to  6  mm.  in  thickness. 

On  histological  examination  the  endometrium  is  found  to  be 

much  thickened.  The 
surface  epithelium  is  in- 
tact. The  majority  of 
the  glands  are  normal. 
A  few  of  them,  however, 
are  dilated.  The  mu- 
cosa shows  a  tendency 
in  some  places  to  pene- 
trate the  uterine  wall 
and  at  one  point  can  be 
traced  into  the  depth  for 
a  distance  of  4  mm.  The 
underlying  muscle  shows 
several  small  myomata 
scattered  throughout  the 
wall.  The  large  porous 
growth  occupying  the 
left  uterine  horn  is  seen 
to  contain  many  islands 
of  mucosa.  One  island 
is  1.8  cm.  in  length  and 
varies  from  1  to  4  mm. 


Fig.  32. — Longitudinal  section  of  discrete  myomata; 
discrete  adenomyoma  near  the  left  uterine 
horn.     (|  natural  size.) 

Gyn.-Path.  No.  7351.  Fig.  32  is  a  longi- 
tudinal of  Fig.  31  from  point  a  to  b.  In  the  anterior  wall 
are  sections  of  two  discrete  niyomata.  The  posterior  wall 
shows  slight  thickening.  The  discrete  adenomyoma, 
although  clearly  defined,  nevertheless  is  intimately  asso- 
ciated with  the  surrounding  muscle  a,  and  could  not  be 
shelled  out  as  could  the  other  two  myomata.  It  contains 
cystic  spaces  as  indicated  by  b.  The  larger  space  has  a 
definite  smooth  lining  and  was  filled  with  yellowish  putty- 
like material, — old  and  inspissated  menstrual  blood. 


in  breadth.  The  uterine 
mucosa  composing  these  islands  differs  little  from  the  ordinary 
mucosa.  Some  of  its  glands  are  dilated  and  contain  old  blood, 
otherwise  it  is  identical. 

Diagnosis  . — Multinodular  uterus,  the  nodules  being  sub- 
peritoneal and  interstitial.  Diffuse  adenomyoma  of  the  uterine 
walls;  discrete  adenomyoma  in  the  left  uterine  horn,  containing  a 
miniature  uterine  cavity. 


DIFFUSE    AI)i;\o.MV<).M  A    OF    THE    UTERI  -  L03 

H.  A.  K.  Sanitarium  No.  2178.     Path.  No.  9803. 
Small   i  n  t  e  r  s  t  i  1  i  a  1    u  t  e  r  i  o  e     m  y  0  m  a  1  a  :     v  e  r  y 

e  a  r  1  y  a  d  e  n  0  m  y  0  m  a  \v  i  t  li  the  m  u  c  0  b  a  e  \  1  e  n  d  - 
i  i)  g     into     the    depth;    s  1  i  g  h  t     pel  vi  C    a  d  li  e  8  i  0  D  8  . 

C.  S.,  aged  forty-six,  white.  Admitted  May  2,  L906  The 
patient  has  been  married  twenty  seven  years  and  has  had  one  child 
and  one  miscarriage.  Her  menses  have  always  been  excessive  and 
lately  the  flow  has  almost  amounted  to  a  flooding.  No  leucorrhoea. 
The  patient  has  been  greatly  debilitated  from  excessive  loss  of 
blood. 

Operation.  May  3d.  Hystero-myomectomy,  double  sal- 
pingo-oophorectomy  and  appendectomy.  This  patient  had  been 
operated  upon  by  Dr.  Kelly  several  years  ago  and  a  number  of 
myomata  had  been  removed.  At  that  time  in  addition  to  the  my- 
omata  there  were  many  adhesions  on  the  left  side  and  the  intestines 
were  slightly  adherent  on  the  right  side.  The  highest  post-operative 
temperature  was  101.2°  F.  The  patient  made  a  satisfactory  re- 
covery. 

Path.  No.  9803  . — The  uterus,  both  anteriorly  and  pos- 
teriorly, is  enveloped  in  adhesions.  It  is  very  little  increased  in  size 
and  contains  three  myomata,  the  largest  1  em.  in  diameter.  The 
right  tube  is  bound  down  to  the  uterus.  Its  fimbriated  end  how- 
ever, is  free.  The  ovary  is  but  little  altered.  The  left  tube  and 
ovary  have  a  few  adhesions,  but  the  fimbriated  end  of  the  tube  is 
normal. 

Sections  from  the  endometrium  show  that  the  tissue  has  been 
very  poorly  hardened  and  that  the  surface  epithelium  is  in  few 
places  intact.  The  glands,  where  preserved,  are  normal.  They 
sho  w  a  c  o  11  s  i  d  e  r  ab  1  e  ten  d  e  n  c  y  to  extend  into 
the  depth.  Sections  from  the  body  o{  the  uterus  show  an 
island  of  mucosa,  2  mm.  in  length,  a  short  distance  below  the  normal 
mucosa.  The  direct  continuity  with  the  surface  can  be  traced. 
The  muscle  beneath  the  mucosa  shows  commencing  diffuse  myo- 
matous transformation. 

Diagnosis  . — Small  interstitial  uterine  myomata  :  very  earlv 


104  ADENOMYOMA    OF   THE    UTERUS 

diffuse  adenomyoma  with  the  mucosa  extending  into  the  depth; 
slight  pelvic  adhesions. 

Gyn.  No.  12,678.     Path.  No.  9466. 

Subperitoneal,  interstitial,  and  submucous 
uterine  myomata;  commencing  adenomyoma 
with    the    glands    originating    from    the   mucosa. 

A.  T.,  married,  aged  fifty-three,  white.  Admitted  February  5, 
1906;  discharged  February  26,  1906.  Complaint:  Pain  at  men- 
strual period,  menorrhagia,  difficulty  in  voiding.  The  patient  was 
in  the  hospital  ten  years  ago  for  nervous  prostration. 

Her  menses  were  regular,  at  first  every  four  weeks,  the  flow  last- 
ing four  days  and  being  normal  in  amount.  There  has  always  been 
marked  dysmenorrhcea  and  the  patient  has  remained  in  bed  three 
or  four  days.  There  has  been  a  gradual  increase  in  the  amount  of 
flow  for  the  past  ten  years.  About  six  weeks  ago  she  noticed  a 
marked  increase  in  amount,  and  from  that  time  to  the  present  the 
flow  has  been  greatly  augmented  Now  the  periods  last  from  four- 
teen to  eighteen  days.  The  pain  is  cramp-like  and  so  severe  as  to 
require  morphin  at  times.  Large  clots  are  passed.  The  patient  has 
never  had  any  children.  For  some  time  the  patient  was  treated 
for  anaemia,  the  real  trouble  not  being  suspected.  She  has  been  con- 
stipated for  some  time  and  has  occasionally  had  hemorrhoids.  There 
is  a  constant  desire  to  urinate,  and  a  feeling  of  pressure  in  the  bladder. 
On  opening  the  abdomen  a  small  amount  of  straw-colored  fluid 
escaped.  On  reaching  with  the  hand  down  into  the  pelvis  a  myo- 
matous mass  was  with  some  difficulty  delivered.  No  adhesions  were 
present.  The  uterus  was  removed  from  left  to  right  without  any 
difficulty.     The  convalescence  was  uneventful. 

Path.  No.  9466  . — The  uterus  is  irregular  in  shape, 
measuring  approximately  12  by  7  by  9  cm.  It  is  free  from  ad- 
hesions and  contains  at  least  four  good-sized  myomata,  the  largest 
reaching  6  cm.  in  diameter.  The  uterine  cavity  is  4.5  cm.  in  length 
and  is  much  distorted  by  a  submucous  myoma  3  cm.  in  diameter 
which  completely  fills  the  cavity. 


DIFFUSE    A.DENOMYOMA    OF   THE    UTERUS  L05 

On  histological  examination  we  have  an  intacl  Burface  epithe- 
lium, normal  glands,  with  here  and  there  hemorrhage  into  the  stroma. 

\V  e    a  1  s  o     h  a  V  e    a     C  0  in  in  e  n  C  i  n  g     <1  i  f  f  n  8  e    thick  e  n  - 

i  n  g  o  f  t  h  e  a  n  t  e  r  i  o  r  u  t e ri  n  e  w  a  1  1  w  i  t h  a  f  1  o  w  - 
i  n  g  (I  o  w  n  o  f  t  h  e  g  1  a  n  <1  s  into  t  h  e  d  e  p  th  .  In  other 
words,  the  picture  is  one  of  a  typical  commencing  adenomyoma. 

Diagnosis.  Subperitoneal,  interstitial,  and  submucous 
uterine  myomata;  commencing  adenomyoma  of  the  anterior  uterine 
wall. 

H.  A.  K.  Sanitarium  No.  1552.     Path.  No.  6536. 

Interstitial  uterine  my  o  m  a  t  a  ;  m  a  r  k  e  d 
penetration  of  the  uterine  m  u  c  0  s  a  into  the 
depth  w  i  t  h  slight  diffuse  myomatous  ten- 
den c y . 

V.  Mc(\,  white,  aged  fifty-three.  Admitted  March  10.  1<>03: 
discharged  April  16,  1903.  The  patient  has  had  five  children.  The 
menopause  occurred  six  months  ago. 

Operation  . — Vaginal  hysterectomy ;  removal  of  the  left 
tube;  repair  of  perineum  and  excision  of  a  vaginal  cyst.  The 
patient  made  a  satisfactory  recovery. 

Path.  X  o  .  6536  . — The  specimen  consists  of  a  mutilated, 
bisected  uterus.  In  the  uterine  walls  are  small  niyomata.  The 
uterus  itself  is  about  normal  in  size.  Sections  from  the  uterine 
wall  near  the  fundus  show  that  the  mucosa  is  normal.  A  t  nu- 
merous points,  however,  the  m  u  c  o  s  a  c  an  b  e 
seen  extending  into  the  underlying  t  i  s  s  u  e 
f  o  r  a  c  o  n  s  i  d  e  r  a  b  1  e  d  i  s  1  a  n  c  e  .  and  farther  out  in  the 
muscle  are  islands  of  mucosa  or  individual  -lands  surrounded  by  a 
small  amount  of  stroma.  There  is  a  distinct  myomatous  tendency, 
as  evidenced  by  the  discrete1  myomata.  The  uterine  walls  them- 
selves, however,  show  little  tendency  toward  diffuse  thickening. 
Sections  from  the  discrete  niyomata  show  the  typical  appearance 
and  hyaline  degeneration. 

Diagnosis. — Interstitial    uterine    myomata.    marked    pene- 


106  ADENOMYOMA    OF    THE    UTERUS 

tration  of  the  uterine  mucosa  into  the  depth,  with  slight  diffuse 
myomatous  tendency. 

Gyn.  No.  11,363.     Path.  No.  7593. 

Subperitoneal,  interstitial,  and  submu- 
cous uterine  myomata.  Diffuse  adenomyoma 
in  the  fundus  with  the  glands  coming  from 
the  mucosa  (Fig.  33) ,  slight  salpingitis;  nor- 
mal   ovaries. 

A.  L.,  colored,  aged  forty-five,  married.  Admitted  June  21, 
1904;  discharged  July  9,  1904.  Complaint:  Uterine  hemorrhages. 
Four  brothers  of  the  patient  died  of  consumption.  Her  previous 
history  is  negative.  Her  menses  were  normal  until  four  years  ago, 
when  the  menopause  occurred.  She  had  one  child,  thirty  years 
ago;    two  miscarriages  about  twenty  years  ago. 

Present  illness :  Nine  months  ago — that  is,  three  years  and  three 
months  after  the  menopause — she  commenced  to  have  some  slight 
uterine  hemorrhage.  This  has  lasted  on  and  off  until  the  present 
time,  but  was  never  profuse.  No  other  symptoms.  She  is  well 
nourished.     Her  lungs  are  normal. 

Operation  . — Hystero-myomectomy.  Convalescence  nor- 
mal. The  highest  temperature  was  101°  F.,  on  the  third  day.  Her 
pulse  varied  from  110  to  130  for  the  first  three  days.  She  was  dis- 
charged on  the  sixteenth  day. 

Path.  No.  7593  . — The  specimen  consists  of  the  uterus 
with  the  tubes  and  ovaries  attached.  The  uterus  is  smooth  and 
its  anterior  surface  is  covered  with  several  nodular  elevations.  It 
measures  12.5  by  8.5  by  10  cm.  and  is  rather  soft. 

On  section  it  is  found  to  contain  submucous,  interstitial,  and 
subperitoneal  myomata.  The  largest  measures  7  by  6  cm.  The 
uterine  cavity  is  7  cm.  in  length.  The  mucosa  in  the  lower  part  of 
the  body  appears  to  be  atrophic.  Near  the  fundus  and  projecting 
into  the  cavity  is  a  polyp  2.5  cm.  in  length.  The  uterine  walls  in 
the  vicinity  of  the  fundus  are  coarsely  striated  and  there  is  a  general 
diffuse   myomatous   tendency    (Fig.    33).     From   the   character   of 


DIFFUSE    A.DENOMYOMA    OF   THE    I    l  ER1  - 


107 


the  growth  we  should  no1  be  surprised  to  find  thai  il  was  an  adeno- 
myoma. 

On    further  examination   il    is   seen   thai    the  entire   fundus   is 
occupied    by  a    diffuse   and  almosl    circular  myoma   which   is  ap- 


f 


/ 


l  r 


u 


Fn;.  :;:;.     Schi'mhiton-eat,,  interstitial  and  submucous   i  mkine  mtomata;   diffuse  u>eno- 

MVoma  OF  THE  ENTIRE  FUNDUS.       (\  n:i1ur:il  size.) 

Gyn.-Pal  b  .    No.    7. "> '.):;.     The  uterine  cavity  has  been  cut   in  two.     In  the  righl 

half  several  polypi  arc  seen.  Scattered  throughout  the  uterine  walU  are  subperitoneal  and  in- 
terstitial niyotnata,  and  at  the  cervix  a  fairly  large  submucous  nodule.  The  uterine  muscle  in  the 
body  shows  a  very  coarse  diffuse  myomatous  appearance  which  instantly  suggests  adenomyoma. 
The  pathological  reporl  shows  that  the  uterine  glands  penetrate  this  diffuse  myomatous  tissue. 


proximately  7  cm.  in  diameter.     S  c  a  1 1  e  r  e  d     I  h  r  o  u  g  h  o  u  t 

t  h  i  s  a  r  e   a  f  e  w  s  p  o  n  g  y   a  r  e  a  s  i  n  d  i  c  a  t  i  v  e    of  m  u  - 

c  o  s  a  ,  a n d  a t    o n  e    point     is    a    d  e  f  i  n  i  \  e    a  r  e  a    of 

mucosa     1  cm.     in     diameter,     surrounded    by    typical 


108  ADEXOMYOMA   OF   THE    UTERUS 

myomatous  tissue.  At  another  point  just  beneath  the  mucosa  is  a 
circumscribed  myoma  in  the  diffuse  growth.  This  contains  three 
or  four  small  cystic  spaces. 

On  histological  examination  some  dilatation  of  the  glands  of 
the  endometrium  is  noticeable,  especially  where  the  polyp  is  present. 
Here  many  of  the  glands  are  fully  four  or  five  times  their  normal 
size.  At  numerous  points  the  mucosa  is  found 
to  extend  into  the  underlying  tissue.  Sections 
a  little  farther  up  in  the  cavity  show  large  areas  of  mucous  mem- 
brane penetrating  into  the  depth,  and  in  the  underlying  tissue  are 
many  islands  of  mucosa  differing  in  no  way  from  the  normal  except 
for  gland  dilatation.  Some  of  the  dilated  glands  contain  a  few 
desquamated  epithelial  cells.  The  ovaries  are  normal.  There  is 
a  slight  degree  of  salpingitis. 

Diagnosis  .—Subperitoneal,  interstitial,  and  submucous  uter- 
ine myomata;  diffuse  adenomyoma  with  the  glands  coming  directly 
from  the  uterine  mucosa. 

Gyn.  No.  701 1.     Path.  No.  3289. 

Multiple  uterine  myomata;  diffuse  adeno- 
myoma, the  glands  originating  from  the  mu- 
cosa.     Peri-oophoritis. 

E.  B.  S.,  aged  thirty-three,  white,  single.  Admitted  June  20, 
1899;  discharged  August  1,  1899.  Complaint:  Menorrhagia;  ab- 
dominal tumor;  dysmenorrhea.  The  menses  began  at  thirteen 
and  were  always  regular,  lasting  seven  days.  There  was  no  severe 
pain,  but  a  cutting  sensation  in  the  left  side.  For  over  a  year  the 
flow  has  been  very  profuse,  amounting  to  hemorrhages.  The  bowels 
are,  as  a  rule,  constipated.     Micturition  is  frequent. 

Operation,  June  24.  Hystero-salpingo-oophorectomy.  The 
right  ovary  was  left  in  situ.  In  addition  to  the  uterus,  a  calcareous 
nodule  was  removed  from  the  mesentery  of  the  ileum  about  10  cm. 
from  the  ileocecal  valve.  The  highest  post-operative  temperature 
was  100.9°  F.,  on  the  ninth  day.  The  patient  made  a  satisfactory 
recoverv. 


DIFFUSE    A.DENOMYOMA    OF   THE    UTERI  -  L09 

P  a  t  h  .  X  o  .  3  2  8  9  .-  The  specimen  consists  of  the  uterus,  left 
tube  and  ovary,  and  several  myomata,  the  largesl   measuring  7.5 

by  5  by  4.5  cm.  The  uterus  Lndependenl  of  some  of  these  large 
nodules  measures  (.)  by  7.5  by  8  cm.  Its  peritoneal  surface  i-  some- 
whal  injected.  The  uterine  cavity  is  (i  cm.  long,  f>  cm.  broad.  At 
the  fundus  the  walls  are  approximately  6  em.  in  thickness.  Small 
myomata  are  seen  scattered  throughout  them.  The  mucosa  is  3  mm. 
in  thickness.  Its  surface  is  very  irregular  owing  to  the  presence  of 
submucous  myomata.  It  is,  for  the  most  part,  smooth  and  glisten- 
ing. 

The  righl  appendages  are  covered  with  adhesions.  On  the  left 
side  the  tube  measures  6  cm.  in  length,  7  mm.  in  thickness.  It  is 
free  from  adhesions.  The  ovary  measures  5  by  4  by  -.')  cm.;  is 
soft  and  fluctuating,  being  apparently  cystic.  It  is  covered  with  a 
few  vascular  adhesions. 

On  histological  examination  sections  from  the  decalcified  cal- 
careous nodule  (3  by  2.5  by  2  cm.)  removed  from  the  mesentery, 
show  that  it  possesses  a  capsule  of  fibrous  tissue  which  contains  a 
few  connective-tissue  cells.  The  centre  of  the  calcareous  area  is 
practically  devoid  of  cell  elements.  The  nodule  appears  to  be  a 
calcified  lymph-gland. 

Sections  from  the  uterine  wall  sh  o  w  dif- 
fuse thickening  with  d  i  r  e  c  1  extension  of 
the    glands    into    the    d  e  p  t  h  . 

Diagnosis. — Multiple  uterine  myomata,  subperitoneal,  in- 
terstitial, and  submucous;  diffuse  adenomyoma.  Pelvic  adhesions; 
hydrosalpinx. 

Gyn.  No.  7859.     Path.  No.  4122. 

M  u  1 1  i  n  o  d  u  1  a  r  m  y  0  m  a  t  0  us  u  1  e  r  u  s  ;  d  i  f  f  u  s  e 
adeno  m  y  0  m  a  oft  h  e  f  und  u  s  (Fig.  34),  w  ith  the 
g  1  a  n  d  s  o  r  i  g  i  n  a  t  i  n  g  f  r  0  m  t  h  e  m  u  c  o  s  a  :  g  e  n  e  r  a  1 
pelvic   adhesions;     r  i  g  b  t    h  a*  m  a  t  o  salpinx. 

A.  B.,  married,  white,  aged  fifty-two.  Admitted  May  29,  1900; 
discharged  June  30.   1900.     Complaint:    uterine  hemorrhage.     The 


110  ADEXOMYOMA  OF  THE  UTERUS 

patient  has  been  married  thirty-six  years,  and  had  one  child,  thirty- 
five  years  ago,  no  miscarriages.  Her  menses  were  normal  until  the 
menopause.  The  patient  has  not  been  in  good  health  for  four  years. 
She  has  had  shortness  of  breath  and  palpitation  for  the  last  three 
years  and  has  been  having  excessive  hemorrhages,  the  bleeding- 
lasting  from  one  week  to  one  month.  She  has  lost  as  much  as  a  basin 
of  blood  in  a  few  minutes,  and  has  had  to  go  to  bed  at  these  times. 
The  bleeding  always  comes  on  after  exertion.  There  has  been  no 
pain.  She  was  formerly  a  robust  woman,  but  has  been  reduced  to 
a  condition  of  great  anaemia.  The  lungs  are  normal.  There  is  a 
soft  systolic  murmur  over  the  entire  cardiac  region.  Haemoglo- 
bin 30  per  cent.  The  urine  contains  a  large  amount  of  pus  and 
some  casts.  For  the  last  three  years  the  patient  has  had  a  greenish, 
offensive  discharge. 

Operation  :  Hystero-myomectomy.  At  the  time  of  her 
discharge,  on  June  29th,  her  haemoglobin  was  59  per  cent.  Just 
about  an  inch  external  to  the  anus  was  a  fistulous  opening.  This 
probably  accounted  for  her  temperature,  which  on  the  third  day 
rose  to  103.5°  F. 

Path.  Xo.  4122  . — The  specimen  consists  of  an  enlarged 
uterus,  the  right  dilated  tube  and  ovary,  and  the  left  tube  and  ovary. 
The  uterus  is  converted  into  a  nodular  tumor  measuring  approxi- 
mately 12  by  10  by  10  cm.  Its  anterior  surface  is  smooth,  but  pos- 
teriorly it  is  covered  with  a  few  adhesions.  The  under  cut  surface  is 
3  cm.  in  diameter.  The  uterine  cavity  is  6  cm.  in  length  and  4  cm. 
in  breadth  at  the  fundus.  The  mucosa  is  smooth,  pale  and  glisten- 
ing, but  is  gathered  up  into  folds,  ridges,  or  polypoid-like  masses, 
in  places  8  or  9  mm.  thick.  Situated  in  the  posterior  wall,  near  the 
junction  of  the  cervix  and  the  tube,  is  an  interstitial  myoma  5  cm.  in 
diameter.  Other  smaller  nodules  are  found  in  the  fundus,  just 
beneath  the  peritoneum.  Both  the  anterior  and  pos- 
terior walls  as  well  as  the  fundus  are  thick- 
ened to  an  average  of  5  cm.  (Fig.  34).  This  hyper- 
trophy  is  most  marked  near  the  mucosa.  Covering  the  outer  surface 
of  the  uterus  is  a  mantle  of  normal  muscle,  1  cm.  thick.     The  thick- 


DIFFUSE    ADENOMYOMA    OF   THE    I    l  ER1  - 


111 


ened  portion  on  section  shows  an  unusually  coarse  arrangement,  the 
fibres  forming  an  irregular  meshwork.  with  here  and  there  a  whorl- 


Adeni  imyi  una 


Img.  34. — Discrete  myoma  of  the  cervix;  diffuse  idenomyoma.  oi   rHEBODYOi   imi  rERUS. 

(Natural  size.  I 

Gyn.-Path.  No.  1122.  a  represents  a  small  portion  of  the  uterine  cavity.  Situated 
;it  the  cervix  is  a  discrete  myoma.  The  uterine  walls  are  greatly  t  hickened  as  a  resull  of  a  diffuse 
myomatous  change.  Scattered  throughoul  this  coarse  tissue  were  large  and  small  yellowish, 
porous  areas  at  once  recognized  as  islands  of  uterine  mucosa.  On  histological  examination  the 
uterine  mucosa  was  seen  literally  pouring  into  the  diffuse  myomatous  muscle.  Covering  the 
outer  surface  is  a  mantle  of  normal  muscle  of  varying  thickness. 


like  arrangement  in  the  interstices.  In  this  m  e  s  h  w  o  r  k 
are  c r  e a  m  y  1  o  o  k  i  n  g  a  r  e  a  s  .  e  v  i  d  en  t  1  y  i  s  1  a  n  tl s 
of    mucosa.      The   line  of  junction   between   the  mucosa   and 


112  ADENOMYOMA    OF   THE    UTERUS 

the  muscle  is  poorly  defined  and  the  muscle  bundles  apparently 
extend  into  the  mucosa. 

The  right  tube  is^converted  into  a  pipe-like  cyst.  The  stem 
itself  is  about  12  cm.  long  and  varies  in  diameter  from  5  mm.  at 
the  cornu  to  14  cm.  at  the  occluded  fimbriated  extremity.  The 
tube  is  covered  with  a  few  adhesions.  Its  walls  are  extremely 
delicate  and  it  contains  dark,  bluish-black  fluid.  The  ovary  is 
small  and  is  covered  with  adhesions.  Situated  in  the  utero-ovarian 
ligament  is  a  myoma,  2.5  cm.  in  diameter.  On  the  left  side  the  tube 
is  8  cm.  long  and  is  covered  with  adhesions.  The  ovary  is  small 
and  is  also  involved  in  adhesions. 

Histological  Examination  . — The  uterine  mucosa 
has  an  intact  surface  epithelium,  as  was  noted  macroscopically.  It 
is  much  thicker  than  usual.  The  gland  elements  are  perfectly 
normal.  Extending  everywhere  into  the  depth 
are  large  rivers  of  mucosa;  in  fact,  the  mu- 
cous membrane  in  the  diffuse  myoma  of  the 
fundus  is  more  abundant  than  that  lining  the 
uterine  cavity.  The  glands  in  the  depth  show  a  certain 
amount  of  dilatation,  and  many  of  them  contain  necrotic  material. 
The  isolated  myomatous  nodule  shows  considerable  hyaline  trans- 
formation. In  places  this  is  quite  sharply  defined  and  many  of  the 
remaining  bundles  stand  out  in  marked  contrast,  reminding  one  at 
first  sight  of  a  malignant  change.  The  right  tube  is  the  seat  of  a 
hydrosalpinx  into  which  there  has  been  hemorrhage.  The  ex- 
tensive invasion  of  the  normal  uterine  mucosa  into  the  myoma 
evidently  accounts  for  the  alarming  hemorrhages  that  at  times  took 
place.  We  have  here  a  myomatous  uterus  with  discrete  myomata 
and  a  widely  diffuse  myoma  occupying  the  fundus.  There  is  no 
question  as  to  the  origin  of  the  glands. 

Diagnosis  . — Multinodular  myomatous  uterus ;  diffuse  adeno- 
myoma  of  the  fundus  with  the  mucosa  literally  running  into  the 
depth.     General  pelvic  adhesions;    right  hematosalpinx. 


DIFFUSE    ADENOMYOMA    OF   THE    I  "I  "l-.l.'i   -  1  L3 

Church  Home  and  Infirmary  No.  1019.     Path.  No.  9407. 

L  a  r  g  c  i  11  t  e  r  s  1  i  I  i  a  I  a  n  d  s  u  l>  m  u  c  o  us  ni  e  r  i  n  e 
in  y  o  m  ;i  t  a  s  li  o  w  i  n  g  li  y  a  line  d e  g  e  o  e  rat  i  o  d  ,  es- 
p  e  c  i  a  1 1  y  p  r  o  n  o  u  n  c  e  <1  in  t  h  e  w  a  lis  of  i  h  e  I)  1  o  o  d  - 
vessels.  Diffuse  a  d  e  n  o  in  y  o  m  ;i  in  i  h  e  w  alls  of 
theuterus,  the  glands  c  o  m  i  n  g  f  r  o  m  t  h  e  m  u  c  o  b  a  . 

W.  B.,  married,  aged  thirty-nine,  white.  Admitted  January  L5, 
l(.)()(i;  discharged  February  12,  1900.  Complaint:  Persistent 
hemorrhage  from  the  uterus.  The  menses  commenced  at  eleven 
and  were  normal  except  that  they  were  rather  profuse.  The  date 
of  i  lie  last  period  is  uncertain.  For  the  past  four  months  the  patient 
has  bled  continuously,  and  the  bleeding  has  been  especially  profuse 
during  the  last  month.  She  has  had  no  pain.  She  had  two  mis- 
carriages thirteen  years  ago,  but  has  never  borne  children.  On 
pelvic  examination  a  mass  is  found  extending  half-way  to  the  um- 
bilicus, occupying  the  entire  superior  strait  of  the  pelvis.  It  is 
rounded  in  outline  and  not  especially  tender. 

Operation  :  Abdominal  hysterectomy.  The  highest  tem- 
perature was  100.8°  F.,  twenty-four  hours  after  the  operation. 

Path.  X  o  .  9407  . — The  specimen  consists  of  the  upper 
part  of  the  uterus.  It  is  globular  and  contains  a  myoma  measuring 
12  by  10  by  10  cm.  The  uterine  cavity  measures  7  cm.  in  length  and 
7  cm.  in  breadth.  The  mucosa,  which  is  somewhat  granular  and 
hemorrhagic,  is  put  on  tension  by  a  large  submucous  myoma.  This 
on  section  shows  some  cystic  areas  and  a  moderate  degree  of  de- 
generation. 

Sections  from  the  endometrium  show  that  the  mucosa,  apart 
from  some  hemorrhage,  is  perfectly  normal.  In  some  places 
the  m  u  c  o  u  s  m  e  m  bra  n  e  c  an  be  s  e  c  n  e  x  t  e  n  d  i  n  g 
into  I  h  e  d  e  p  t  li  f  o  r  a  c  o  n  s  i  d  e  r  a  b  1  e  d  is  t  a  n  c  e  .  and 
in  the  vicinity  we  have  isolated  glands  or  bunches  of  glands  surround- 
ed by  stroma,  and  lying  in  the  depth.  The  muscle  shows  a  definite 
myomatous  tendency.  Sections  from  the  myoma  show  a  good  deal 
of  hyaline  degeneration,  particularly  pronounced  around  the  blood- 
vessels. 

8 


114  ADEXOMYOMA  OF  THE  UTERUS 

We  have  here  a  large  interstitial  and  partly  submucous  myoma 
showing  hyaline  degeneration,  and  also  a  fairly  well-defined  diffuse 
adenomyoma  of  the  body  of  the  uterus  with  the  glands  originating 
in  the  mucosa. 

Gyn.  No.  11,252.     Path.  No.  7507. 

Subperitoneal  and  interstitial  uterine 
my  o  mat  a;  diffuse  adenomyoma  of  the  uter- 
ine   walls;    subperitoneal    adenomyoma. 

F.  S.,  colored,  aged  forty-four.  Admitted  May  5,  1904;  dis- 
charged June  2,  1904.  Complaint :  Pain  in  the  left  side.  The  patient 
had  always  had  considerable  dysmenorrhcea.  She  had  been  married 
twenty-one  years,  but  had  never  been  pregnant.  She  complained  of 
a  burning  discomfort  during  the  first  two  days  of  menstruation,  and 
for  some  years  had  had  continued  pain  in  the  left  ovarian  region. 
She  was  well  nourished.  Several  small  myomata  were  detected 
and  the  uterus  was  retroflexed  and  adherent.  It  was  decided  to 
remove  the  uterus,  as  the  patient  was  near  the  menopause  and  as 
she  had  come  such  a  long  distance  for  treatment  (Jamaica) . 

Operation  :  Hystero-nryomeetomy.  The  highest  tempera- 
ture was  100.5°  F.,  on  the  second  day.     Convalescence  normal. 

Path.  X  0  .  7507  . — The  uterus  has  been  amputated  through 
the  cervix  and  is  4  cm.  in  length.  On  the  posterior  surface  is  a 
pedunculated  myoma,  1  cm.  in  diameter.  Just  above  this  is  a 
slight  elevation.  On  section  the  uterine  walls  are  found  to  vary 
from  1.5  to  1.8  cm.  in  thickness.  Scattered  throughout  the  uterine 
tissue  are  a  few  minute  myomata.  In  the  anterior  wall  about  its 
middle  is  an  irregular  mass,  1  cm.  in  diameter.  This  is  not  sharply 
circumscribed,  but  gradually  blends  with  the  surrounding  uterine 
muscle. 

On  histological  examination  the  uterine  mucosa  shows  much 
thickening.  The  surface  epithelium  is  intact.  The  stroma  cells 
immediately  beneath  are  swollen,  somewhat  resembling  decidual 
cells,  and  the  tissue  shows  a  great  deal  of  small  round-cell  and  poly- 
morphonuclear infiltration.     The  glands  in  the  depth  show  marked 


DIFFUSE    A  MYXOMYOMA    OF   THE    UTERUS  115 

hypertrophy  and  t h e r e    is    a    peculiar    tendency    for 

t  li  c  m     i  ii  (I  i  v  i  (I  u  ;i  1  I  y     o  r     i  n     l>  U  n  C  li  e  8     I  o     e  x  1  e  ii  d 
<|  ii  i  1  e    ;i    (list  a  n  c  e    into    I  li  e    u  n  d  e  r  1  y  i  D  g    in  USCle  , 

u  s  u  a  1  I  y   a  c  c  <>  in  p  a  n  i  e  d    b  y    I  li  e  i  r  s  I  r  o  w  a  . 

The  myoma  in  (lie  anterior  wall  is  diffuse  in  character  and  con- 
tains islands  of  uterine  mucosn  ;iik1  also  isolated  glands,  the  majority 
of  which  are  associated  with  the  characteristic  stroma  of  the  mucosa. 
Some  of  the  "lands,  however,  lie  in  direct  contact  with  the  muscle. 

We  have  here  a  uterus  smaller  than  normal,  one  subperitoneal 
and  several  interstitial  myomata,  an  endometrium  which  is  thicker 
than  usual  and  which  shows  definite  invasion  into  the  muscle.  We 
also  have  a  partially  subperitoneal  adenomyoma  which  is  somewhat 
diffuse  in  character  and  blends  with  the  surrounding  muscle.  We 
have  not  the  slightest  doubt  that  such  a  uterus  in  time  would  be 
the  seat  of  a  wide-spread  diffuse  adenomyoma. 

H.  A.  K.  Sanitarium  No.  1453.     Path.  No.  6216. 

Diffuse  adenomyoma  of  the  anterior  a  n  d 
posterior  uterine  walls  (Fig.  35).  The  gland 
elements  are  derived  from  the  uterine  mu- 
cosa. 

H.  C,  married,  white,  aged  forty-seven.  Admitted  October  20, 
1902;  discharged  December  11,  1902.  The  patient  has  had  four 
children.  Her  menses,  which  were  regular,  have  lately  become  ir- 
regular and  more  frequent. 

Operation  :  Pan-hysterectomy;  repair  of  the  perineum: 
removal  of  a  urethral  caruncle.  The  patient  made  a  satisfactory 
recovery. 

P  a  th  .  X  o  .  0  2  1  6  . — The  uterus  is  13  cm.  in  length,  1<>  cm. 
in  breadth,  and  9  cm.  in  its  antero-posterior  diameters.  Its  surface 
is  smooth  and  glistening,  except  near  the  fundus.  There  are  a  few 
adhesions  and  the  tubes  and  ovaries  are  bound  down.  The  uterus 
is  about  the  size  of  that  of  a  three  and  a  half  months'  pregnancy. 
The  cervical  canal,  which  is  curved,  is  about  3  cm.  in  length.  T  h  e 
increase  in  size  of  the  uterus  is  due  to  a  marked 


116 


ADENOMYOMA    OF    THE    UTERUS 


diffuse  thickening  of  the  anterior  wall, which 
reaches  7  cm.  in  thickness  (Fig.  35) .  Scattered 
throughout     the     thickened    and    diffuse   m  y  o  - 


Fig.  35. — Diffuse  adexomyo.ma  of  the  body  of  the  uterus.     (f  natural  size.) 

Gyn.-Path.  No.  6216.  A  longitudinal  section  through  the  entire  uterus.  Sur- 
rounding the  uterine  cavity,  which  looks  normal,  is  a  broad  zone  of  diffuse  myomatous  tissue, 
much  thicker  in  the  anterior  than  in  the  posterior  wall.  Covering  this  is  a  mantle  of  normal 
muscle,  a,  but  at  the  fundus  the  coarse  myomatous  tissue  almost  reaches  the  peritoneum.  Sec- 
tions show  that  the  uterine  mucosa  extends  into  the  depth  and  that  many  islands  of  mucous 
membrane  are  scattered  throughout  the  myomatous  tissue. 


matous  tissue  are  a  few  cystic  spaces  lined 
with  a  delicate  velvety  membrane.  The  posterior 
uterine  wall  varies  from  2.2  to  2.5  cm.  in  thickness.     Its  texture  is 


DIFFUSE    A.DENOMYOM A    OF   Till;    [JTERUS  11/ 

also  coarse.  but  the  si  rial  ion  is  not  as  marked  as  in  the  anterior  wall. 

Covering  the  diffuse  growth  in  both  the  anterior  and  posterior  wall 

is  a  mantle  of  normal  uterine  muscle.  The  uterine  cavity  is  small, 
about  4.5  cm.  in  length. 

On  histological  examination  the  uterine  mucosa  is  found  to  be 
slightly  thickened,  but  otherwise  normal.  The  diffuse  thickening 
in  the  anterior  wall  is  due  to  a  diffuse  myomatous  transformation  of 
the  muscle.  Scattered  abundant!  y  1  h  r  o  u  g  h  t  h  e 
m  y  o  m  a  t  o  u  s  m  u  s  c  1  e  are  la  r  g  e  a  n  d  small  i  s  - 
1  a  n  d  s  o  f  uterine  m  u  c  o  s  a  .  Some  of  these  are  fully  8  mm. 
in  length.  Here  and  there  the  glands  are  dilated;  otherwise  this 
mucosa  differs  in  no  way  from  that  lining  the  uterine  cavity,  and 
at  many  points  the  uterine  mucosa  can  be  traced  directly  into  the 
myoma.  In  the  posterior  wall  there  is  also  a  diffuse  adenomyoma. 
Here  likewise  the  continuity  with  the  surface  mucosa  can  be  traced. 

In  this  case  there  is  a  diffuse  mantle  of  myomatous  tissue  sur- 
rounding the  entire  uterine  cavity,  markedly  developed  in  the 
posterior  wall;  and  penetrating  this  mantle  are  large  areas  of  uterine 
mucosa. 

Diagnosis. — Diffuse  adenomyoma  of  the  anterior  and 
posterior  uterine  walls.  The  gland  elements  are  derived  from  the 
uterine  mucosa. 

Gyn.  No.  12,358.     Path.  No.  8983. 

Subperitoneal,  interstitial  and  submu- 
cous u  ferine  m  y  o  m  a  t  a  ;  s  1  i  g  h  t  en  d  ometritis; 
diffuse  a  d  e  n  o  m  y  0  m  a  w  i  t  h  the  u  t  e  r  i  n  e  g  1  a  n  d  s 
e  x  t  e  n  d  i  n  g  into  the  depth;  a  d  e  n  o  m  y  o  m  a  tons 
areas    in    the    left    uterine    h  o  r  n  . 

S.  S.,  aged  thirty-one,  black,  married.  Admitted  September  11, 
L905;  discharged  October  2,  1905.  Complaint:  A  painful  lump 
in  the  left  side  of  the  abdomen  and  uterine  hemorrhages.  The 
menses  commenced  at  thirteen,  were  always  regular  but  painful,  and 
are  now  profuse.  The  flow  lasts  three  days.  There  is  some  pain 
for  twelve  hours  previous  to  the  flow.     She  has  been  married  twice. 


118  ADENOMYOMA    OF   THE    UTERUS 

She  had  one  pregnancy  six  or  seven  years  ago,  normal  until  the 
sixth  month,  when  a  premature  labor  came  on  as  the  result  of  a 
fall.  The  child  was  born  dead.  Nine  months  ago  patient  noticed 
a  lump  in  the  left  side,  which  has  been  almost  constantly  painful. 
She  knows  nothing  about  the  growth  of  the  tumor.  She  says  that 
the  tumor  pushes  upward  and  causes  discomfort,  which  she  can 
relieve  by  pressing  down  upon  it  with  her  hand.  There  have  been 
no  changes  in  the  menstrual  flow  until  two  months  ago,  when  there 
was  increased  pain  and  the  flow  was  excessive,  but  without  clots. 
One  month  ago  the  period  did  not  appear  at  the  expected  time,  but 
there  was  an  excessive  flow  of  a  clear  watery  fluid.  There  has  been 
much  tenderness  since  she  first  noticed  the  tumor.  No  nausea  or 
vomiting. 

Operation  :  Hystero-myomectomy ;  double  salpingectomy, 
left  oophorectomy.  The  highest  post-operative  temperature  was 
101.4°  F.     Convalescence  was  uninterrupted. 

Path.  No.  8983  . — The  specimen  consists  of  an  irregularly 
globular  uterus,  12  cm.  from  side  to  side,  12  cm.  in  length,  and  14  cm. 
in  its  antero-posterior  diameter.  Posteriorly  it  is  covered  by  tags 
of  adhesions,  none  of  which  are  very  dense.  In  the  anterior  wall  is 
a  myoma  7  cm.  in  diameter.  In  the  posterior  wall  is  a  myoma 
measuring  8  by  9  cm.  Attached  to  the  right  side  just  behind  the 
tube  is  a  nodule  7  cm.  in  diameter.  This  is  attached  by  a  pedicle, 
2  cm.  in  breadth,  5  mm.  in  thickness.  This  myoma  on  section 
presents  a  dark  appearance  in  places  and  has  undergone  slight  ne- 
crosis. 

The  left  tube  is  normal.  The  ovary  is  covered  with  a  few  ad- 
hesions.    The  right  tube  is  normal . 

Sections  from  the  endometrium  show  that  it  has  been  poorly 
hardened.  The  glands  show  a  moderate  degree  of  hypertrophy. 
Here  and  there  they  extend  for  a  short  distance  into  the  muscle. 
There  is  some  small  round-cell  infiltration.  Sections  from  the 
fundus,  which  are  better  preserved,  show  considerable  small  round- 
cell  infiltration  in  the  superficial  layers,  and  in  the  depth  far  down 
are  here  and  there  glands  some  of  which   show  the  characteristic 


DIFFUSE    ADENOMYOMA    OF   THE    I  TER1  -  1  L9 

pseudo-glomeruli  described  byvon  Recklinghausen,  the  spaces  being 
lined  with  cuboida]  epithelium  and  a  projection  of  stroma  into  the 
cavity  being  noted.  This  projection  also  is  covered  with  epithelium, 
and  in  the  spaces  between  this  and  the  so-called  capsule  is  desqua- 
mated epithelium.  Near  the  outer  surface  the  gland-like  spaces 
are  nnich  more  abundant.  They  are  everywhere  surrounded  by 
muscle,  and  some  of  the  larger  spaces  reach  2  mm.  in  diameter. 
They  are  lined  with  one  layer  of  cuboidal  epithelium  which  rests 
directly  on  the  muscle. 

On  further  section  of  the  uterine  mucosa  we  find  a  t  e  n  d  e  n  c  y 
f  o  r  t  h  e  g  lands  to  extend  i  n  t  o  the  d  e  p  t  h  i  n 
1  he  form  of  a  wedge.  Sections  taken  from  near  the  left 
cornu  show  that  the  tube  presents  some  slight  degree  of  small  round- 
cell  infiltration  just  beneath  the  epithelium.  Surrounding  this  in 
many  places  are  glands  lined  with  one  layer  of  epithelium  rest  in- 
directly on  the  muscle,  or  separated  from  it  by  a  small  amount  of 
stroma.  Some  of  the  gland-like  spaces  are  dilated,  their  epithelium 
is  flattened,  and  they  are  filled  partly  with  blood,  partly  with  serum. 

Diagnosis  . — Subperitoneal,  interstitial,  and  submucous 
myomata ;  slight  endometritis;  diffuse  adenomyoma  of  the  uterine 
wall  with  invasion  of  the  mucosa  into  the  depth;  adenomyomatous 
areas  in  the  left  uterine  horn ;  slight  adhesions  of  the  ovaries. 

Emergency  Hospital,  Frederick,  Md.     Path.  No.  8393. 

Diffuse  adenomyoma  of  the  anteri  o  r  a  n  d 
posterior  uterine  walls;  1  a  r  g  e  c  y  s  t  i  C  s  p  a  c  e  s 
in  the  uterine  h  0  r  n  d  u  e  to  d  i  1  a  t  a  t  i  o  n  o  f  por- 
tions of  the  a  d  e  n  o  m  y  o  m  a  t  o  u  s  e  1  e  m  e  n  t  s  Fig. 
36) .  The  g  1  a  n  d  elements  in  t  h  e  d  i  f  f  u  s  e  g  r  o  w  t  h 
a  i-  e  c  1  e  a  r  1  y  s  h  o  w  n  to  1)  e  d  e  rival  i  V  e  s  of  t  h  e 
u  t  e  r  i  n  e    m  u  c  o  s  a  . 

Y.  AY.,  aged  fifty-three.  Operated  upon  February  3,  1905. 
The  patient  lias  been  suffering  for  some  time  from  a  myomatous 
uterus  and  has  had  frequent  uterine  bleeding.  On  opening  the 
abdomen  we  found  a  myomatous  uterus  about   the  size  of  that  of  a 


120 


ADEXOMYOMA   OF    THE    E/TERUS 


four  months'  pregnancy.  Numerous  nodules  were  present.  The 
cervix  was  adherent.  Posteriorly  and  on  the  right  side  was  a  hy- 
drosalpinx. The  tumor  was  removed  with  little  difficulty  and  the 
patient  made  a  satisfactory  recovery. 

Path.  X  o  .  8393  . — The  specimen  consists  of  a  large  glob- 
ular uterus  and  of  the  appendages  on  both  sides.  The  uterus  has 
been  amputated  through  the  cervix.  It  is  12  cm.  in  length,  15  cm. 
from  side  to  side,  and  10  cm.  in  its  antero-posterior  diameters. 
Covering  its  surface  posteriorly  are  a  few  delicate  adhesions.     On 


Fig.  36. — Diffuse  adenomyoma  of  the  fundus  with  cystic  spaces  in  the  left  uterine 

horn,      (i  natural  size.) 

Gyn.-Path.  Xo.  8393.  The  entire  fundus  is  converted  into  a  diffuse  myomatous 
tissue  and  with  the  low  power  the  uterine  mucosa  can  be  seen  penetrating  the  myoma  in  all 
directions.  The  cystic  space  a,  in  the  left  uterine  horn  is  due  to  gland  dilatation,  it  being  lined 
with  cylindrical  ciliated  epithelium.  The  space  b  is  filled  with  blood.  On  the  right  side  is  a 
tubo-ovarian  cyst.     The  inner  pole  of  the  right  ovary  is  normal. 


examination  it  is  found  that  the  thickening  in  the 
uterus  is  due  to  a  diffuse  myomatous  ar- 
rangement around  the  uterine  cavity  (Fig.  36) . 
The  thickening  in  both  the  anterior  and  the  posterior  wall  reaches 
5  cm.  There  is  likewise  a  tendency  toward  a  circumscribed  diffuse 
area  2.5  cm.  in  diameter.  The  uterine  mucosa  is  apparently  consid- 
erably thickened.  The  general  picture  instantly  reminds  one  of  a 
diffuse  adenomyoma  occupying  both  the  anterior  and  the  posterior 
wall  and  encircling'  the  fundus. 


DIFFUSE    ADENOMYOMA    OF   THE    UTERUS  L21 

In  the  Left  uterine  eornu  is  an  irregular  cystic  space,  (>  by  1  cm. 
This  is  partially  divided  by  septa  and  has  delicate  trabecular  passing 

from  side  to  side.  The  cysl  walls  in  the  outer  portion  vary  from 
1  to  3  nun.  in  thickness.  The  riuht  tube  has  been  converted  into  a 
hydrosalpinx,  which  at  its  outer  end  is  (.)  cm.  in  diameter.  The  ri-ht 
ovary  is  apparently  Qormal.  The  left  tube  is  enveloped  in  delicate 
adhesions.  Its  fimbriated  end  is  patent.  The  ovary  is  very  small 
and  apparently  contains  a  corpus  luteum  cyst   1  cm.  in  diameter. 

In  the  lower  portion  of  the  uterus  is  a  myomatous  whorl  2  cm. 
in  diameter,  and  near  the  centre  of  this  is  a  cystic  area  8  mm.  in 
diameter  filled  with  yellowish  contents. 

Sections  from  the  body  of  the  uterus  show  that  the  uterine 
mucosa  has  not  been  well  preserved  owing  to  faulty  hardening. 
It  can  at  several  points  be  traced  d  i  r  e  c  1 1  y 
into  the  depth  for  a  considerable  distance. 
Scattered  abundantly  throughout  the  diffuse  myomatous  growth, 
in  the  anterior  as  well  as  in  the  posterior  wall,  are  islands  of  uterine 
mucosa,  sometimes  also  an  individual  gland  surrounded  by  stroma, 
and  then  again  an  area  of  mucosa  containing  imperfectly  preserved 
glands.  The  same  picture  is  noted  no  matter  where  the  section 
comes  from.  Where  the  diffuse  myomatous  growth  ends  the  glands 
also  end. 

Sections  from  the  cyst  in  the  left  eornu  show  that  it  is  lined  with 
one  layer  of  ciliated  epithelium.  The  myomatous  nodule  with  the 
cystic  centre,  containing  yellowish  material,  presents  a  very  in- 
teresting  picture.  The  nodule  consists  of  typical  myomatous  tissue. 
The  cystic  space  is  filled  with  coagulated  contents,  fragments  of 
nuclei,  and  a  few  polymorphonuclear  leucocytes,  and  the  walls  of 
this  cavity,  partly  organized,  contain  numerous  small  round  cells. 
This  has  evidently  been  a  portion  of  a  miniature  uterine  cavity 
from  which  the  epithelium  has  disappeared  and  a  partially  organized 
blood-clot  has  taken  its  place. 

Diagnosis. — Diffuse  adenomyoma  of  the  anterior  and 
posterior  uterine  walls;  large  cystic  spaces  in  the  left  uterine  horn, 
evidently   due   to   dilatation   of   portions   of   the   adenomyomatous 


122  ADENOMYOMA  OF  THE  UTERUS 

elements.     The  gland  elements  in  the   diffuse  growth  are  clearly 
shown  to  be  derivatives  of  the  uterine  mucosa. 

H.  A.  K.  Sanitarium  No.  19 13.     Path.  No.  8641. 

Subperitoneal  and  interstitial  uteri  ne 
myomata;  commencing  diffuse  adenomyoma 
of    the    uterine    walls;      normal    appendages. 

McC,  white,  aged  fifty-two,  married.  Admitted  April  27,  1905; 
discharged  June  9,  1905.  In  1885  the  patient  had  pulmonary 
tuberculosis,  a  left  pyelonephritis,  and  an  infected  bladder. 

Present  condition:  The  periods  are  regular  but  profuse.  The 
patient  has  had  a  tumor  which  has  been  increasing  in  size  for  some 
time. 

Operation  :  Hystero-myomectomy  and  appendectomy. 
The  patient  was  of  a  very  nervous  temperament,  but  made  a  satis- 
factory recovery. 

Path.  No.  8641  . — The  specimen  consists  of  a  myomatous 
uterus  which  would  be  practically  normal  in  shape  were  it  not  for  a 
subperitoneal  nodule  projecting  far  out  from  the  left  side.  The 
uterus  with  the  nodule  is  9  cm.  in  length,  8  cm.  in  breadth,  and  1 1  cm. 
in  its  antero-posterior  diameter.  It  is  smooth  and  glistening. 
Projecting  from  the  posterior  surface  just  behind  the  insertion  of 
the  left  tube  is  a  nryomatous  nodule  approximately  7  cm.  in  diameter. 
The  uterus  on  section  is  found  to  be  riddled  with  myomata.  In  the 
upper  part  the  nodule  is  3  cm.  in  diameter.  The  uterine  cavity  is 
5  cm.  in  length  and  the  mucosa  2  mm.  in  thickness. 

The  appendages  on  both  sides  are  normal. 

Sections  from  the  mucosa  show  that  the  surface  epithelium  is 
intact.  The  glands  are  normal.  There  is  a  tendency 
for  the  glands  to  dip  down  into  the  depth,  and 
here  and  there  it  is  possible  to  trace  them  for 
a  considerable  distance.  Undoubtedly  we  have  here 
a  commencing  adenomyoma. 

Diagnosis  . — Subperitoneal  and  interstitial  uterine  my- 
omata;  commencing  diffuse  adenomyoma. 


DIFFUSE    A.DENOMYOMA    OF   THE    UTERI  -  L23 

H.  A.  K.  Sanitarium   No.   1944.     Path.  No.  8807. 

M  u  1 1  i  p  1  e  uteri  d  e  m  y  0  m  a  t  a  .  s  u  b  p  eril  0  n  e  a  1 . 
interstitial,    a  11  d    s  u  b  m  u  c  ous;    dif  f  u  s  e  a  d  e  □  0  - 

111  y  0  m  a  <  0  u  s  1  h  i  c  k  e  n  i  n  g  in  1  h  e  a  0  t  eri  0  r  a  d  d 
posterior  uteri  n  e  W  alls  \v  i  t  h  d  i  r  e  C  t  ex  1  e  D  - 
e i  0 d  0 f  t  h e  u  t  e  r  i n e  m u c 0 s a  into  t  h  e  d  e p  t h , 
t  0  g  ether  with  t  h  e  f  0  r  m  a  t  ion  0  f  a  in  iniatu  r  e 
u  t  e  r  i  n  e  c  a  v  i  t  y  . 

A.  C,  married,  aged  forty-eight.  Admitted  May  17,  1905. 
Discharged  June  21,  1905.  The  patient  has  been  married  twenty- 
two  years,  has  had  three  children  and  one  miscarriage  three  years 
ago.  The  menses  are  normal.  There  has  been  some  watery  leu- 
corrhceal  discharge.  The  patient  is  very  frail  and  has  lost  somewhal 
in  weight.  Her  haemoglobin  is  40  per  cent.  She  has  had  chronic 
constipation.  Pier  family  and  previous  history  are  not  important. 
For  about  a  year  she  has  noticed  that  her  abdomen  has  been  growing 
rapidly  and  she  has  had  constant  backache.  She  suffers  from  fre- 
quent vesical  irritation  and  obstinate  constipation. 

Operation,  May  18.  Hystero-salpingo-oophorectomy. 
After  the  operation  this  patient  had  a  slight  infection  about  the 
cervix  which  caused  some  elevation  in  temperature — 100.4°  F.  on 
one  occasion.     The  temperature  gradually  subsided. 

Path.  N  o  .  8807  . — The  specimen  consists  of  a  nodular 
myomatous  uterus  with  appendages.  The  uterus  is  approximately 
12  cm.  in  length,  12  cm.  in  breadth,  and  S  cm.  in  its  antero-posterior 
diameters.  It  is  for  the  most  part  smooth  and  glistening.  Pro- 
jecting from  the  surface  are  pedunculated  and  sessile  myomata,  and 
scattered  throughout  the  walls  are  a  few  other  nodules.  Projecting 
from  the  right  side  and  extending  out  into  the  broad  ligament  is  an 
irregular,  nodular,  myomatous  growth,  which  measures  15  by  18  by 
14  cm.  This  is  partly  covered  by  peritoneum,  but  beneath  the 
smooth  surface  is  a  good  deal  of  adipose  tissue,  evidently  from  the 
broad  ligament,  and  coursing  over  the  anterior  surface  is  the  right 
round  ligament,  which  can  be  traced  for  a  distance  of  12  cm.  Very 
little  of  the  uterine  cavity  is  to  be  seen  except  in  the  upper  portion. 


124  ADENOMYOMA  OF  THE  UTERUS 

The  uterine  mucosa  varies  from  2  to  3  mm.  in  thickness.  Three  mm. 
beneath  the  mucosa  is  a  miniature  uterine  cavity,  4  mm.  in  diameter, 
filled  with  coagulated  chocolate-colored  fluid,  and  lined  with  a 
mucosa  1  mm.  in  thickness.  Just  beneath  the  peritoneal  surface  of 
the  uterus  are  a  few  cyst-like  spaces,  the  largest  2  mm.  in  diameter. 
The  tubes  and  ovaries  look  normal. 

Sections  from  the  fundus  show  a  most  instructive  picture.  The 
surface  epithelium  is  intact.  The  glands  are  to  a  great  extent 
normal,  but  some  are  much  dilated,  others  skein-like.  The  mu- 
cosa is  flowing  down  everywhere  into  the 
underlying  tissue.  In  some  places  it  can  be 
traced  by  direct  continuity  for  6  or  7  mm. 
The  mucosa  that  flows  into  the  depth  is  perfectly  normal  except  for 
here  and  there  some  gland  dilatation.  On  the  opposite  side  of  the 
cavity  we  are  able  to  trace  the  mucous  membrane  for  1  cm.  into 
the  underlying  myomatous  muscle.  Here  and  there  a  small  band 
of  mucosa  will  pass  down  and  then  branch  out  in  all  directions. 
The  brownish  area  apparently  surrounded 
by  a  definite  mucosa  and  noted  macroscopic- 
ally  is  a  miniature  uterine  cavity.  This  cavity 
is  filled  with  blood  and  is  lined  with  one  layer  of  high  cylindrical 
epithelium.  Opening  into  it  are  numerous  glands  surrounded  by 
the  characteristic  stroma  of  the  mucosa. 

Diagnosis  . — Multiple  uterine  myomata,  subperitoneal, 
interstitial,  and  submucous;  diffuse  adenomyoma  of  both  the 
anterior  and  posterior  walls,  the  gland  elements  being  distinctly 
derivatives  of  the  uterine  mucosa. 

The  presence  of  adenomyoma  was  immediately  suspected  as  soon 
as  the  chocolate-colored  area  surrounded  by  a  definite  lining  of 
mucosa  was  detected.  As  a  rule,  no  other  condition  in  the  uterus 
would  give  rise  to  such  a  picture. 


CHAPTER  V 

SUBPERITONEAL  AND  INTRALIGAMENTARY  ADENOMYOMATA 

Subperitoneal  and  intrali^amentary  adenomyomata  arc  con- 
sidered together,  inasmuch  as  the  process  is  similar  in  both  instances, 
namely,  the  extension  to  the  outer  surface  of  the  uterus.  If  situated 
above  the  middle  of  the  uterus,  the  adenomyomata  tend  to  become 
subperitoneal;  below  this  point  and  lateral  to  the  uterus  they  are 
likely  to  spread  out  between  the  folds  of  the  broad  ligament. 

SUBPERITONEAL  ADENOMYOMATA 

Subperitoneal  adenomyomata  may  be  very  small  and  com- 
pletely isolated,  as  seen  in  Fi<>;.  61,  p.  219,1  in  which  an  adenomyoma 
less  than  1  cm.  in  diameter  was  found  in  a  patient  operated  upon 
for  adenocarcinoma  of  the  body  of  the  uterus.  The  two  processes 
were  entirely  independent  of  each  other.  This  small  nodule,  to  the 
unaided  eye,  differed  in  no  way  from  an  ordinary  myomatous  nodule. 

Subperitoneal  adenomyomata  may,  on  the  other  hand,  be  of 
goodly  size.  Fi"-.  37  represents  a  subperitoneal  nodule  measuring 
13  by  10  by  8  cm.  and  attached  by  a  broad  base.  As  seen  from  the 
drawing,  it  was  partly  cystic,  partly  solid.  The  distal  or  free  portion 
had  been  converted  into  a  thin-walled  and  irregular  cysl  partially 
filled  with  blood.  The  solid  portion  consisted  of  myomatous  tissue 
traversed  by  several  small  cysts,  some  not  more  than  1  mm.  in 
diameter,  others  are  more  than  1  cm.  On  histological  examinatioD 
the  large  cyst  was  found  to  be  in  the  vicinity  of  the  solid  area,  lined 
with  one  layer  of  cylindrical  epithelium;  bu1  where  the  walls  were1 
very  tense  and  thin,  the  epithelium  had  become  very  low  or  had 
entirely  disappeared.  In  Fig.  38,  a  low  magnification,  it  is  seen 
that   the  cystic  spaces  scattered  throughout    the  solid  portion  are 

lCullen,  Thomas  S.:   Cancer  of  the  Uterus,  L900,  p.  460. 

1 25 


126  ADEXOMYOMA    OF    THE    UTERUS 

dilated  glands  lined  with  one  layer  of  cylindrical  epithelium.  Some 
of  these  are  separated  from  the  muscle  by  the  typical  stroma. 

In  neither  of  the  foregoing  cases  was  there  any  evidence  of  adeno- 
myomata  in  the  body  of  the  uterus. 

In  Case  3293  we  have  another  example  of  a  cystic  subperitoneal 
adenomyoma.  As  noted  in  the  history,  the  uterus  was  greatly  in- 
creased in  size,  chiefly  owing  to  the  presence  of  a  large  submucous 
myoma  and  a  huge  subperitoneal  and  pedunculated  myoma  spring- 
ing from  the  left  side.  Projecting  from  the  right  side  of  the  fundus 
was  a  nodule  measuring  6  by  5.5  by  5  cm.  This  was  soft  and  boggy, 
and  over  an  area  fully  5  cm.  in  diameter  was  made  up  of  thin-walled 
cysts  (Fig.  39;.  On  histological  examination  the  cyst  walls  were 
found  to  consist  of  myomatous  tissue  and  the  cavities  were  lined 
with  one  layer  of  cylindrical,  ciliated  epithelium  (Fig.  40).  The 
cells  closely  resembled  those  of  the  normal  uterine  mucosa.  In 
some  places  the  walls  of  the  cavity  were  gathered  up  into  little 
papillary -like  folds.  In  other  places,  irregular  gland-like  cavities 
were  found  scattered  throughout  the  walls.  These  closely  resembled 
the  gland  hypertrophy  so  often  seen  in  the  uterine  mucosa.  In. a 
few  places  the  walls  of  the  cysts  showed  evidence  of  old  hemorrhages, 
their  cells  having  taken  up  large  quantities  of  fine  yellow  granular 
pigment.  Here  also  we  have  a  subperitoneal  adenomyoma  with 
elements  closely  resembling  uterine  mucosa. 

San.  Xo.  1872  is  the  most  striking  example  of  a  subperitoneal 
myoma  that  we  have  ever  seen.  Fig.  41,  p.  142,  gives  the  relative 
contour  of  the  uterus.  It  was  the  seat  of  a  diffuse  adenomyoma. 
At  a  is  a  subperitoneal  and  pedunculated  myoma  which  is  partly 
cystic.  On  section  of  this  subperitoneal  nodule  we  found  large 
islands  of  mucosa,  and  the  cystic  areas  formed  miniature  uterine 
cavities  filled  with  chocolate-colored  contents.  The  islands  of 
mucosa  and  also  the  cystic  spaces  are  depicted  in  Fig.  42,  p.  144. 

Of  interest  is  the  case  of  Xeumann.1     In  a  woman  forty-four 

1  Neumann,  Siegfried:  Ueber  einen  neuen  Fall  von  Adenomyom  des  Uterus 
und  der  Tuben  mit  gleiehzeitiger  Anwesenheit  von  Urnierenkeimen  im  Eierstock. 
Arch.  f.  Gynaek.,  1899,  Bd.  lviii,  S.  593. 


SUBPERITONEAL   AM)    [NTRALIGAMENTARl     U5ENOMYOMATA       127 

years  of  age  he  found  an  intersl  i<  i;il  myoma,  the  size  of  a  fist,  and  on 
the  anterior  surface  of  the  uterus  in  the  vicinity  of  the  cervix  a 

subserous  myoma,  I  lie  size  of  a  walnut.  Lying  in  dose  proximity 
to  this  was  a  cyst  as  large  as  a  hen's  egg.  This  had  a  broad  base. 
The  walls  of  the  cyst  were  composed  of  uterine  muscle,  near  the  base 
having  a  thickness  of  3  mm.,  but  becoming  thinner  until  at  the  con- 
vex and  free  surface  they  were  not  thicker  than  parchment.  The 
inner  surface  of  the  cyst  was  smooth  and  the  cavity  contained  a 
coagulated,  friable,  grayish  mass.  In  the  vicinity  of  these  cysts 
were  two  others,  the  size  of  hazelnuts  and  with  very  thin  walls. 
Situated  in  the  tissue,  at  the  base  of  these  two,  was  still  another 
cyst  about  as  large  as  a  bean.  This  was  subdivided  into  several 
smaller  cavities.  The  large  cyst  had  a  wall  composed  of  muscular 
tissue  and  was  lined  with  a  single  layer  of  cylindrical  ciliated  epithe- 
lium. This  rested  on  a  connective-tissue  stroma,  which  separated 
it  from  the  muscle.  Scattered  throughout  the  myomatous  muscle 
were  glands  bearing  a  marked  resemblance  to  uterine  glands  and 
surrounded  by  stroma  similar  to  that  of  the  uterine  mucosa.  Neu- 
mann says  that  this  was  undoubtedly  a  large  adenomyoma  of  the 
uterus,  cystic  in  character.  There  was  also  an  adenomyomatous 
polyp  in  the  uterine  cavity  and  another  adenomyoma  in  one  of  the 
uterine  horns.  He  was  unable  to  trace  any  connection  between  the 
uterine  mucosa  and  the  adenomvomata. 

Among  the  most  remarkable  subperitoneal  adenomvomata  of 
the  uterus  ever  reported  wTas  the  "voluminous"  tumor  of  Pick.1 
which  occurred  in  a  woman  forty-one  years  old,  sprang  from  the 
posterior  surface  of  the  uterus,  and  was  adherent  to  the  anterior 
abdominal  wall  and  to  the  intestinal  loops.  Landau  experienced 
much  difficulty  in  its  removal.  The  tumor,  as  shown  in  the  illustra- 
tion which  Professor  Pick  kindly  sent  me,  presented  a  very  coarse 
shaggy  appearance.  It  consisted  of  many  large,  blunt,  papillary 
masses,  and  in  the  vicinity  of  the  median  line  tin1  mass  contained  a 
glistening,  slimy,  cystic  tumor,  about  the  size  of  a  man's  head.     It 

1  Tick,  Ludwig:  Ein  neuer  Typus  des  voluminoseD  paroophoralen  Adenomy- 
oms.     Arch.  t'.  Gynaek..  Bd.  liv.  S.  117. 


128  ADENOMYOMA  OF  THE  UTERUS 

was  everywhere  adherent.  The  cyst  cavity  contained  clear  muco- 
colloid  material.  On  the  surface  of  the  growth  were  many  isolated 
nodules  consisting  of  myomatous  tissue  and  containing  large  and 
small  spaces.  Pick  found  that  the  solid  portions  of  the  tumor  con- 
sisted of  a  fibromyomatous  substance  surrounding  well-formed 
glandular  tissue.  This  glandular  tissue  consisted  of  cylindrical 
glands  lined  with  a  single  layer  of  cylindrical  epithelium.  Sometimes 
the  glands  occurred  in  groups  and  were  surrounded  by  a  definite 
stroma;  others  showed  cystic  dilatation.  From  the  description  it 
is  seen  that  this  tumor  was  a  subperitoneal  and  adherent  adeno- 
mvoma. 

Cases  of  Subperitoneal  Adenomyoma 
Gyn.  No.  8647.  Path.  No.  4838. 
Diffuse  adenomyomatous  thickening  of 
the  uterine  walls;  interstitial  and  subperi- 
toneal myomata;  slight  edema  of  the  uter- 
ine mucosa  with  extension  of  the  gl  ands  into 
the  depth.  Subperitoneal,  cystic  adeno- 
myoma.     (Figs.  37  and  38.) 

F.  M.  R.,  single,  aged  forty,  white.  Admitted  April  8,  discharged 
May  2,  1901.  The  patient  was  operated  upon  for  hemorrhoids  two 
years  ago.  Her  menses  began  at  twelve  and  were  regular,  lasting- 
three  days.  For  several  years  at  the  menstrual  period  the  patient  has 
complained  of  headache  and  nausea.  There  has  been  no  marked 
disturbance  of  menstruation  at  any  time,  but  occasionally  the  period 
has  been  delayed  a  few  days.  The  last  period  occurred  one 
week  ago. 

The  patient  does  not  know  when  she  first  noticed  a  lump  in  the 
right  side  of  the  abdomen.  In  the  beginning  it  was  about  the  size 
of  an  egg,  but  for  the  last  year  has  been  increasing.  There  has  been 
no  pain  or  discomfort  associated  with  it.  The  general  condition 
has  been  good. 

In  the  right  lower  abdomen  is  a  definite  prominence.  This  is 
firm  on  palpation,  distinctly  movable,  and  reaches  to  a  point  2  cm. 


SUBPERITONEAL   AND    [NTRALIGAMENTAR1    ADENOMYOMATA      L29 

below  the  umbilicus.  It  is  smooth  and  oblong  in  shape  The  in- 
guinal glands  are  palpable,  bul  nol  tender. 

Operation  April  loth.  A  large  multinodular  myomatous 
litems  was  exposed.     The  uterus  was  bisected  and  removed.     The 

tubes  we're  likewise  removed,  but  the  ovaries  were  left  in  -situ.  The 
patient  was  discharged  in  excellent  condition  on  the  twenty-third 
day. 

Gyn.-Path.  N  o  .  4  8  3  8  . — The  specimen  consists  of  a 
bisected,  multinodular  uterus  and  of  both  tubes.  One  nodule, 
which  projected  from  the  right  cornu  and  was  attached  by  a  pedicle, 
4  cm.  in  diameter,  measures  13  by  10  by  S  cm.  Its  inner  half  is 
firm  and  dense;  its  outer  portion  is  soft  and  cystic,  but  everywhere 
covered  with  smooth  peritoneum  (Fig-.  37).  On  section  the  solid  por- 
tion of  this  nodule  is  seen  to  be  made  up  of  typical  myomatous  tissue, 
but  at  two  points  are  seen  irregular  cystic  areas  1  and  2  cm.  in 
diameter  respectively.  The  smaller  of  these  has  a  smooth  inner 
surface  and  apparently  a  definite  lining.  The  large  cystic  portion 
of  the  subperitoneal  myoma  contains  a  single  cavity,  approximately 

7  cm.  in  diameter.  The  walls  of  this  vary  from  1  mm.  to  1  cm.  in 
thickness;  the  cavity  contains  a  thick,  viscid,  chocolate-colored 
substance.  The  uterus  is  very  irregular  in  form  and  has  project  ing 
from  its  surface  numerous  small  myomatous  nodules.     It  measures 

8  by  8  by  5  cm.  The  tubes  are  apparently  normal,  but  attached  to 
the  fimbriated  extremity  of  one  of  them  is  a  subperitoneal  cysl  meas- 
uring 1.5  by  1  cm. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — Sections  from  the 
uterine  cavity  show  that,  where  the  mucosa  has  been  protected, 
there  is  an  intact  surface  epithelium,  slightly  flattened  but  perfectly 
normal.  The  uterine  glands  are  normal  in  number.  Near  the  cavity 
they  are  narrow,  but  in  the  vicinity  of  the  muscle  are  much  convo- 
luted. The  gland  epithelium  is  normal.  The  stroma  of  the  mucosa 
just  beneath  the  surface1  epithelium  shows  considerable  edema. 
At  one  point  in  the  uterine  eavii  y  t  h  e  m  u  c  o  sa 
is  seen  penetrating  the  m  u  s  c  1  e  to  a  d  e  p  t  h  of 
1  .  5  m  m  .  Here  the  glands  are  dilated  and  surrounded  by  diffuse 
9 


130 


ADENOMYOMA    OF    THE    UTERUS 


myomatous  tissue.  The  uterine  walls  show  partial  myomatous 
transformation  of  their  muscle  bundles,  and  scattered  throughout 
the  walls  are  numerous  small  myomata.  Some  of  these  are  not 
more  than  1  mm.  in  diameter. 


Fig.  37. — A  cystic  subperitoneal  adenomtoma  of  the  uterus.     (Natural  size.) 

Gyn.-Path.  No.  48  3  8.  The  drawing  represents  one-half  of  the  tumor,  which  was 
attached  to  the  enlarged  fundus  by  the  very  short  broad-based  pedicle  situated  in  the  vicinity  of 
d.  The  tumor  is  roughly  divided  into  a  semi-solid  and  a  cystic  portion.  The  cyst  is  irregular  in  out- 
line and,  as  seen  in  Fig.  38,  at  a  it  connects  with  little  bays  extending  off  into  the  solid  portion. 
In  some  places  the  cyst  wall  is  very  thin,  as  at  a.  The  ragged  appearance  in  the  interior  of  the  cyst 
and  the  smooth  homogeneous  substance  just  within  the  cyst  wall  are  due  to  coagulated  cyst  con- 
tents. The  inner  surface  of  the  cyst  is  in  reality  smooth  and  velvety.  The  solid  portion  of  the 
tumor  is  composed  of  a  diffuse  myoma.  Scattered  throughout  it  are  large  and  small  cyst-like 
spaces,  b  is  such  a  cavity.  It  is,  however,  irregular  in  form  and  branches  out  considerably.  It 
has  a  smooth  inner  lining.  In  the  space  c  the  coagulated  contents  still  remain.  There  are  also 
numerous  smaller  spaces  scattered  throughout  the  myomatous  tissue.  These  spaces,  on  careful 
study,  do  not  convey  the  idea  of  cysts,  but  it  seems  as  though  the  muscle  were  being  tunnelled  in 
various  directions  by  spaces  of  variable  size.     For  the  very  low  magnification  see  Fig.  38. 

Sections  from  the  large  subperitoneal  myoma  show  a  very  in- 
teresting picture.  This  nodule  consists  essentially  of  myomatous 
tissue,  but  here  and  there  bundles  of  normal  muscle  still  remain 
(Fig.  38).  The  small  cyst-like  spaces  noted  in  the  solid  portion  of 
the  tumor  have  an  inner  lining  of  a  single  layer  of  cylindrical  and 


SUBPERITONEAL    WD    [NTRALIGAMENTARI     ADENOMYOMATA      131 


apparently  ciliated  epithelium.  This  is  in  mosl  places  separated 
from  the  surrounding  myomatous  tissue  by  a  stroma  somewhal 
resembling  thai  of  the  uterine  mucosa;    and  scattered  throughout 

the  stroma  are  occasional  small  glands  identical  with  those  of  the 
uterine  mucosa.     At  some  points  in  these  cysts  the  epithelial  lining 


Fig.  38. — A  cystic  subperitoneal  adenomyoma  of  the  uterus,     i  1  \  Datura]  size. 

Gyn.-Path.    No.   4  8  3  8  .     The  sect  ion  is  through  the  same  tumor  as  Fig.  37,  bul  a< 

another  level.  A  is  the  same  large  cyst  cavity.  It  has  a  small  bay  (a)  extending  off  to  the  left. 
It  is  lined  with  a  single  layer  of  epithelium,  which  from  the  text  is  seen  to  lie  cylindrical.      Jusl 

beneath  the  epithelial  lining  a1  6  is  a  small  gland :  c  represents  the  coagulated  cysl  content-.  /•' 
and  C  are  irregular  cyst-like  spaces  lined  with  one  layer  of  epithelium.    In  the  aeighborhood  of  d 

are  numerous  small  glands,  also  lined  with  cylindrical  epithelium.  Some  of  t  he  glands,  notably  al  -  . 
are  surrounded  by  a  definite  circular  zone  of  myomatous  muscle.      The  deeply  staining  area-,  as 

seen  at  <■',  are  the  myomatous  muscle  bundles.  The  intervening  pale  framework  i-  a  somewhal 
rarefied  connective  tissue.     We  should  not  be  much  surprised  if  at  one  time  all  the  large  cysl 

cavities  communicated  with  one  another. 

has  disappeared  and  the  underlying  tissue  shows  distinct  evidences 
of  old  hemorrhage.  These  cyst-like  spaces  contain  a  variable  quan- 
tity of  Mood.  Scattered  throughout  the  solid  portion  of  this  sub- 
peritoneal nodule  are  numerous  smaller  cysts  varying  from  1  to  3 
mm.  in  diameter.     These  are  lined  with  one  layer  of  cylindrical  epithe- 


132  ADEXOMYOMA    OF    THE    UTERUS 

Hum  and  are  separated  from  the  muscle  by  a  definite  stroma,  They 
contain  a  good  deal  of  blood.  One  of  these  cysts  may  be  roughly 
likened  to  a  cross-section  of  a  miniature  uterine  cavity,  as  it  is 
partially  surrounded  by  glands  similar  to  those  of  the  uterine  mucosa. 
Scattered  here  and  there  throughout  the  myoma  are  similar  glands, 
the  majority  lying  in  direct  contact  Math  the  uterine  muscle  and  not 
being  surrounded  by  stroma.  It  is  particularly  interesting  to  note 
that  the  myomatous  tissue  is  most  dense  immediately  around  the 
cyst-like  spaces.  The  large  cystic  portion  of  the  subperitoneal 
myoma  consists  essentially  of  one  cavity.  Near  the  solid  portion, 
where  there  has  not  been  much  opportunity  for  stretching,  this 
cyst  is  lined  with  one  layer  of  fairly  well  preserved  cylindrical  and 
apparently  ciliated  epithelium.  Sometimes  this  epithelium  rests 
directlv  on  the  muscle,  but  in  many  places  is  separated  from  it  by 
stroma  similar  to  that  of  the  mucosa;  in  this  stroma  the  blood- 
vessels are  often  greatly  dilated.  As  we  gradually  approach  the 
more  prominent  portion  of  the  cyst,  where  the  walls  are  very  thin, 
the  epithelial  lining  becomes  thinner  and  thinner  and  entirely  dis- 
appears. Clinging  to  the  inner  surface  here  is  fibrin,  holding  in  its 
meshes  a  variable  quantity  of  blood.  As  is  clearly  evident  from  the 
description,  this  is  a  subperitoneal  adenomyoma  which  has  become 
cystic.  Although  we  have  cut  many  sections,  it  has  been  impossible 
to  trace  a  direct  connection  between  the  uterine  mucosa  and  the  glands 
of  the  subperitoneal  adenomyoma,  Nevertheless,  we  have  seen  that 
the  uterus  shows  a  diffuse  myomatous  transformation  and  that  the 
uterine  glands,  at  one  point  at  least,  are  commencing  to  extend  into 
the  depth. 

Diagnosis  . — Diffuse  myomatous  thickening  of  the  uterine 
walls;  interstitial  and  subperitoneal  myomata;  slight  edema  of 
the  uterine  mucosa  with  commencing  extension  of  the  glands  into 
the  depth;  subperitoneal  cystic  adenomyoma, 

Gyn.  No.  3293.     Path.  No.  583. 
Subperitoneal,        interstitial,        and        sub- 
mucous    myomata.       Multiple    cysts   in    a    sub- 


SUBPERITONEAL    AM)    [NTRALIGAMENTARY     \  DENOM  V  »M  \'l  A       L33 

peritoneal    myoma    (Figs.  39  and   in.     Atrophy    and 

edema     of    the     uterine    mucosa.         Double     pe  r  i- 

s  al  pi  n  g  it  is  and  p  e  r  i  o  6  p  h.  or  i  t  is  .  11  y  s  t  er  e  c  - 
1  o  m  y  .       R  e  c  o  v  e  r  y  . 

P.  S.,  single,  aged  forty,  colored.  Admitted  January  23,  L895; 
discharged  February  24,  1895.  One  child,  twenty  years  ago;  no 
miscarriages.  The  menses  appeared  at  fifteen;  they  were  regular 
but  painful.  Since  the  onset  of  the  present  trouble  they  have  been 
much  more  profuse,  lasting  three  days  and  accompanied  by  intense 
pain.  The  patient  has  had  a  thin  bloody,  offensive,  leucorrhoeal 
discharge,  containing  shreds  for  two  weeks  after  each  menstrual 
period,  then  giving  place  to  a  white,  offensive  discharge  lasting  until 
the  next  period. 

Ten  years  ago  she  noticed  a  small  lump  in  the  abdomen,  more 
prominent  during  menstruation.  The  tumor  has  grown  steadily 
and  now  practically  fills  up  the  abdomen;  there  has  been  some 
dull  pain  over  the  region  of  the  mass  (following  an  accidental  blow 
thereon),  the  pain  being  more  severe  at  menstrual  periods. 

Examinatio  n  . — The  abdomen  is  much  distended  by  a  hard. 
sensitive,  irregular  mass.  The  cervix  is  pushed  against  the  sym- 
physis; the  whole  vaginal  vault  is  filled  with  a  hard  immovable 
mass. 

0  per  a  t  ion.  January  30,  1895.  Panhystero-myomectomy. 
General  peritoneal  adhesions,  three  large  subserous  myomata;  sub- 
mucous myoma;  involvement  of  posterior  lip  of  cervix  necessitating 
panhysterectomy.     Recovery. 

Gyn.-Path.  No.  5  8  3  .—The  specimen  consists  of  a 
large  irregularly  shaped  uterus,  with  tumors  springing  from  both 
sides.  The  portion  of  the  uterus  present  is  approximately  14  cm. 
long,  14  cm.  broad,  and  15  cm.  in  its  antero-posterior  diameter. 
The  anterior  surface  is  roughened  and  anteriorly  and  posteriorly 
it  is  covered  with  many  dense  adhesions.  Springing  from  the  an- 
terior and  posterior  surfaces  are  somewhat  flattened  nodules,  vary- 
ing from  1  to  4  cm.  in  diameter.  The  under  cut  surface  of  the 
uterus  is  9  cm.  in  diameter  and  the  cervical  canal,  which  is  completely 


134 


ADENOMYOMA    OF    THE    UTERUS 


blocked  by  a  reddish  injected  mass,  is  5.5  cm.  from  side  to  side.     The 
uterine  walls  average  3  cm.  in  thickness.     Their  muscle  fibres  are 


Fig.  39. — A  subperitoneal  cystic  adenomyoma  occurring  in  the  case  of  a  large  myo- 
matous uterus.    (|  natural  size.) 

Gyn.-Path.  No.  583.  The  uterus  is  much  enlarged,  owing  to  the  presence  of  myo- 
matous tumors.  Projecting  through  the  cervix  is  a  small  portion  of  a  submucous  myoma  and 
situated  anteriorly  and  to  the  left  are  the  large  myomata  a  and  b,  only  dimly  outlined.  The  right 
tube,  although  lengthened,  is  little  altered.  It  is  attached  to  the  ovary  by  a  few  bands.  Scattered 
over  the  posterior  surface  of  the  uterus  are  several  sessile  nodules  and  one  of  moderate  size  with 
several  cysts  springing  from  its  surface,  c  is  a  single  cyst  and  at  d  a  group  of  seven  are  seen.  All 
are  thin- walled  and  semi-translucent.  As  learned  from  the  text,  they  are  not  subperitoneal  cysts, 
their  walls  being  composed  of  myomatous  tissue,  and  furthermore  they  are  lined  with  a  single  layer 
of  cylindrical  epithelium.     For  the  histological  picture  see  Fig.  40,  which  is  taken  from  the  area  d. 


SUBPERITONEAL    A.ND    [NTRALIGAMENTAR1     ADENOMYOMATA       L35 

much  coarser  than  usual,  and  scattered  here  and  there  throughout 
the  walls  are  whitish  nodules  varying  from  .5  to  2.5  cm.  in  diameter. 
'The  port  ion  of  the  uterine  cavity  present  is  L2  cm.  in  length,  and 
springing  into  it  are  several  nodules,  the  largest  reaching  2.5  cm.in 
diameter.  The  uterine  mucosa  is  pinkish-white  in  color  and  aver 
1 .5  mm.  in  thickness.  ( )ver  the  large  nodule  it  is  somewhat  atrophic. 
Projecting  into  the  cavity  from  the  left  side  is  an  irregular,  globular, 
pear-shaped  mass  measuring  16  by  10  by  10  cm.  It  is  the  lower 
portion  of  this  that  projects  through  the  cervix.  This  nodule  pres- 
ents depressions  corresponding  to  the  small  submucous  nodules. 
It  is  covered  with  mucosa  which  is  apparently  very  edematous. 
The  mucosa  averages  1  mm.  in  thickness,  but  where  edematous  is 
fully  4  or  5  mm.  thick.  Springing  from  the  right  side  of  the  uterus 
is  a  nodule,  6  by  5.5  by  5  cm.  This  is  covered  with  adhesions,  and 
has  springing  from  it  numerous  subperitoneal  cysts  forming  a  mass 
fully  5  cm.  in  size.  The  tumor  is  soft  and  boggy.  Projecting  from 
the  left  side  of  the  body  of  the  uterus  are  two  kidney-shaped  masses. 
The  larger  measures  22  by  13  by  11  cm.,  is  pinkish  in  color,  slightly 
lobulated,  and  is  covered  with  numerous  adhesions  binding  it  to  the 
uterus  and  the  adjoining  tumor.  The  adhesions  are  very  vascular. 
The  smaller  tumor  measures  12  by  7  by  S  cm.  and  closely  resembles 
its  neighbor.  The  uterine  tumors  on  section  are  pinkish-white  in 
color  and  for  the  most  part  consist  of  fibres,  having  a  concentric 
arrangement.  The  large  tumor  to  the  right  of  the  uterus  contains 
areas,  fully  2.5  cm.  in  diameter,  consisting  of  a  fine  network  of  fibres 
traversing  a  cavity  filled  with  clear  transparent  fluid.  Numerous 
smaller  but  similar  areas  are  scattered  throughout  the  tumor.  They 
are  undoubtedly  areas  of  degeneration.  The  small  kidney-shaped 
nodule  springing  from  the  fundus  presents  numerous  small,  yellow- 
ish-white, granular  areas  foci  of  calcification.  The  small  and  soft 
nodule  to  the  right  of  the  uterus  shows  some  degeneration.  This 
nodule  on  section  is  found  to  be  partially  cystic  over  an  area  5.5  cm. 
(Fig.  39).  These  cysts  in  the  hardened  specimen  vary  from  the 
size  of  a  pea  to  ;>.5  cm.  in  diameter;  they  have  exceedingly  thin  walls, 
smooth  inner  surfaces,  and  at  once  suggest  a  multilocular  ovarian 


136 


ADENOMYOMA    OF    THE    UTERUS 


cyst.  There  are  numerous  similar  areas  scattered  throughout  the 
tumor.  There  is  absolutely  no  connection  between  the  ovary  and 
this  tumor,  as  the  latter  is  situated  8  cm.  from  the  ovary. 

The  tubes  and  ovaries  are  enveloped  in  dense  adhesions. 

Histological  Examination  . — The  uterine  mucosa 
is  much  atrophied,  but  near  the  fundus,  where  it  is  somewhat  pro- 
tected, it  reaches  3  mm.  in  thickness.  The  surface  presents  an  intact 
epithelium.     The  glands  are  in  places  abundant,   in  other  parts 


Fig.  40. — Cystic  subperitoneal  adenomtoma  of  the  uterus.     (6  diameters.) 

Gyn.-Path.  No.  .58  3.  The  section  is  from  point  d,  Fig.  39.  a  is  the  solid  myoma- 
tous portion  of  the  tumor;  b  is  the  thin  myomatous  layer  forming  the  outer  walls  of  the  cysts  c  and 
d.  The  outer  peritoneal  covering  is  represented  by  b' .  The  cyst  spaces,  c  and  d,  have  convoluted 
inner  surfaces  and  at  many  points  (e)  there  are  gland-like  depressions.  The  cysts  and  also  the 
depressions  are  lined  with  a  single  layer  of  cylindrical  ciliated  epithelium.  Situated  in  the  myo- 
matous tissue  at  /  and  /  are  two  gland-like  spaces  which  bear  a  most  striking  resemblance  to  hyper- 
trophic uterine  glands,     g  is  the  edge  of  a  neighboring  cyst. 


scanty.  Some  are  small  and  round  on  cross-section,  others  are 
slightly  dilated,  but  all  have  an  intact  epithelium.  The  stroma  of 
the  mucosa  is  of  a  moderate  density  and  is  composed  of  cells  having 
oval  or  elongate-oval  nuclei.  Over  the  small  submucous  nodule  at 
the  fundus  the  mucosa  has  almost  entirely  disappeared.  The  surface 
is  here  covered  with  epithelium  which  in  some  places  is  cylindrical, 
in  other  places  almost  flat,  while  at  some  points  it  is  two  or  three 
layers  in  thickness,  is  swollen,  and  resembles  squamous  epithelium. 
Beneath  the  surface  epithelium  are  a  few  stroma  cells  and  beneath 


SUBPERITONEAL    AM)    [NTRALIGAMENTAR1     A  DENOM  V  >M  AT  A      i£t 

these. -ire  Qumerous  small  round  cells.     The  glands  al  this  point  have 
entirely  disappeared.    The  mucosa  over  the  Large  submucous  nodule 

in  the  most  prominent  portions  is  represented  by  one  layer  of  epithe- 
lium, which  is  poorly  defined,  being  almost  flat.  Beneath  this  is 
a  small  amount  of  stroma,  hut  all  of  the  glands  have  disappeared. 
Where  the  mucosa  looked  edematous  the  epithelium  covering  the 
surface  is  intact,  but  rests  directly  on  the  muscle,  there  being  no 
intervening  stroma.  The  muscle  has  undergone  partial  or  complete 
hyaline  degeneration  and  has  in  many  places  practically  disappeared, 
leaving  a  colorless  tissue,  scattered  throughout  which  are  a  few  small 
round  cells,  red  blood-corpuscles,  and  polymorphonuclear  leucocytes. 
The  portions  that  have  not  yet  broken  down  show  numerous  cells 
which  have  taken  up  golden-yellow  pigment.  Taken  as  a  whole, 
the  mucosa,  where  present,  is  normal, but  where  subjected  to  pressure 
has  undergone  partial  or  almost  complete  atrophy.  In  some  places 
it  shows  considerable  edema. 

The  nodules  scattered  throughout  the  uterus  or  situated  on  its 
outer  surface  are  composed  of  non-striped  muscle  fibres  which  have 
been  cut  in  various  directions.  They  all  show  a  moderate  amount 
of  localized  or  diffuse  hyaline  degeneration. 

The  cystic  portion  of  the  nodule  situated  to  the  right  of  the  uterus 
presents  a  very  unusual  picture.  The  cyst  walls  are  composed  of 
tissue  that  cannot  be  distinguished  from  the  muscle  fibres  of  the 
part  and  the  cyst  cavities  are  lined  with  a  single  layer  of  cylindrical 
epithelium  (Fig.  40).  The  nuclei  of  the  epithelial  cells  are  oval  or 
almost  round  and  are  situated  near  the  centres  of  the  cells.  These 
cells  are  ciliated  and  closely  resemble  the  epithelium  covering  the 
surface  of  the  uterine  mucosa.  In  some  places  the  walls  of  the  cavity 
are  gathered  up  into  little  papillary-like  folds;  in  other  places  ir- 
regular, convoluted,  gland-like  cavities  are  found  scattered  through- 
out the  walls.  These  are  very  strongly  suggest ive  o'l  gland  hyper- 
trophy as  seen  in  the  uterine  mucosa.  In  a  few  places  the  walls  of 
these  cysts  show  evidence  of  hemorrhage,  their  cells  having  taken 
up  large  quantities  of  hue  yellow  granular  pigment.  These  glands 
and  cvsts  occurring  in  the  myoma  are  evidently  due  to  embryonic 


138  ADENOMYOMA    OF    THE    UTERUS 

displacements.  I  am  inclined  to  think  that  they  have  been  derived 
from  Mliller's  duct:  (1)  because  the  epithelium  bears  such  a  striking- 
likeness  to  that  of  the  uterine  mucosa;  and  (2)  because  of  the  pig- 
ment in  the  cyst  wall.  If  these  cysts  are  derivatives  of  Mliller's 
duct,  we  should  naturally  expect  them  to  take  part  in  the  menstrual 
flow.  The  blood  resulting  cannot  escape  and  must  needs  be  taken 
up  by  the  cyst  walls.  This  will  account  for  the  pigment.  The  ap- 
pendages are  covered  with  numerous  adhesions,  but  are  otherwise 
normal. 

Diagnosis  . — Subperitoneal,  interstitial,  and  submucous 
myomata.  Multiple  cysts  in  a  subperitoneal  myoma,  these  cysts 
probably  being  due  to  remains  of  Mliller's  duct.  Atrophy  and 
edema  of  the  uterine  mucosa.  Double  perisalpingitis  and  peri- 
oophoritis. 

Gyn.  No.  9024.    Path.  No.  5187. 

Subperitoneal  and  partly  interstitial  a  d  e  - 
nomyoma  removed  by  excision  through  the 
abdomen. 

L.  C,  married,  aged  thirty-eight.  Admitted  August  30,  .1901; 
discharged  September  2,  1901.  The  patient  entered  complaining 
of  constant  uterine  hemorrhage.  Her  periods  have  never  been 
regular.  Since  she  had  typhoid  when  twenty  years  of  age,  the 
duration  of  the  flow  has  been  increased  and  the  intervals  have  been 
gradually  growing  shorter.  In  July  of  this  year  (1901)  she  was  ad- 
mitted to  the  hospital,  and  previous  to  this  had  had  constant  bleed- 
ing for  nine  weeks,  with  considerable  dysmenorrhea.  Shortly  after 
admission  to  the  hospital  she  was  curetted.  Three  weeks  after 
leaving  the  hospital  she  had  another  period,  and  bleeding  has  con- 
tinued ever  since,  becoming  more  and  more  profuse  and  occasionally 
being  clotted.     The  patient  has  pain  in  her  back  and  lower  abdomen. 

Operation  . — Abdominal  myomectomy,  hysterotomy,  curet- 
tage and  suspension  of  the  uterus.  Two  small  nodules  were 
found  in  the  posterior  surface  of  the  uterus.  These  were  removed. 
The  uterus  was  then  split,  the  cavity  exposed,  and  the  mucous  mem- 


SUBPERITONEAL    WD    [NTRALIGAMENTAIH     ADENOMYOMATA      L39 

brane  found  to  be  apparently  normal.  The  cervix  was  dilated  from 
above.  The  uterus  was  then  suspended  in  the  usual  way.  The 
patienl  made  a  satisfactory  recovery. 

Path.  No.  5187.  The  specimen  consists  of  a  small  amount 
of  curettings  and  of  a  piece  of  tissue  1.8  cm.  in  diameter.  The  surface 
of  this  tissue  presents  a  smooth  peritoneal  covering.  Beneath  this 
is  a  dense  nodular  myoma,  5  mm.  in  diameter.  In  the  centre  of 
this  nodule  is  a  cavity,  2  by  1  mm.,  lined  with  a  very  thin  smooth 
membrane.  Sections  show  the  tumor  to  be  a  typical  myomatous 
growth,  and  scattered  throughout  it  are  several  cysts  lined  with  a 
definite  mucosa.  The  epithelium  lining  the  cavity  is  of  the  cy- 
lindrical variety.  The  underlying  stroma  is  similar  to  that  of 
the  uterine  mucosa.  The  growth  is  a  typical  adenomyoma.  Of 
course,  it  is  impossible  for  us  to  trace  any  relationship  with  the  uter- 
ine mucosa,  as  the  uterus  was  not  removed. 

Gyn.  No.  9637.     Path.  No.  5840. 

A  d  e  n  o  m  y  o  m  a  a  p  p  a  r  e  n  t  1  y  subperitoneal  : 
remove d  t  h  r o  u g h  the  a  b d  o  m  e  n . 

I.  D.,  colored,  married,  aged  nineteen.  Complaint:  Cramps  in 
the  lower  left  side  of  the  abdomen.  Her  menses  were  normal  up  to 
a  year  ago.  Since  then  there  has  been  cramp-like  pain  in  the  lower 
abdomen.  She  has  had  one  child  and  one  miscarriage.  Her  periods 
now  last  longer  than  formerly. 

Operation  :  Abdominal  myomectomy.  The  patient  made 
a  satisfactory  recovery  and  was  discharged  on   the  twentieth  day. 

Path.  No.  5840  . — The  specimen  consists  of  a  mutilated 
myoma  which  is  oval  in  shape  and  approximately  2.5  cm.  in  diameter. 

On  h  i  s  t  o  1  0  g  i  c  a  1  e  x  a  m  i  n  a  t  i  0  n  this  presents  the 
typical  myomatous  appearance,  and  scattered  throughout  it  are 
areas  which  resemble  uterine  mucosa.  It  is  a  clear  case  of 
adenomyoma.  apparently  subperitoneal. 

D  i  a  g  n  o  sis  . — Adenomyoma,  apparently   subperitoneal. 


140  ADENOMYOMA  OF  THE  UTERUS 

Gyn.  No.  12,585.     Path.  No.  9336. 

Gland  hypertrophy.  Small  uterine  myo- 
mata.  Adenomyoma,  apparently  subperito- 
neal, 4  mm.  in  diameter. 

K.  H.,  married,  aged  thirty-five,  white.  Admitted  December  28, 
1905;  discharged  January  17,  1906.  Complaint:  Pain  in  the  lower 
abdomen;  a  leucorrhceal  discharge  and  a  bearing-down  sensation 
in  the  pelvis.  The  menses  began  at  twelve  and  were  regular  every 
twenty-eight  days.  The  flow  was  rather  scanty  and  occasionally 
clotted.  The  last  period  occurred  three  weeks  ago.  The  patient 
has  been  married  four  years  but  has  had  no  children.  She  is  some- 
what emaciated;  the  mucous  membranes  are  rather  pale. 

Operation  :  Dilatation  and  curettage.  Abdominal  my- 
omectomy, resection  of  right  ovary.  Several  small  myomata  were 
removed  from  the  uterus.  The  patient  made  a  very  satisfactory 
recovery.     The  highest  post-operative  temperature  was  100°  F. 

Path.  No.  9336  . — The  specimen  consists  of  a  moderate 
amount  of  curettings  and  of  two  nodules  from  the  right  ovary  and 
two  myomata  from  the  uterus. 

On  histological  examination  we  find  gland  hyper- 
trophy, a  corpus  luteum,  and  two  small  myomata.  One  myoma 
presents  the  usual  appearance  and  shows  hyaline  transformation. 
A  note  was  made  that  macroscopically  one  of  these  small  nodules 
from  the  uterus  looked  like  a  little  black  vesicle  and  somewhat 
resembled  a  thrombosed  vein.  It  is  a  myoma  containing  small 
cystic  spaces.  The  cystic  spaces  are  lined  with  one  layer  of  epithe- 
lium and  are  filled  with  blood.  In  the  immediate  vicinity  are 
several  small  gland-like  spaces  and  some  stroma.  The  growth  is  a 
typical  adenomyoma.     It  is  not  over  4  mm.  in  diameter. 

Diagnosis  . — Gland  hypertrophy ;  discrete  uterine  myo- 
mata and  discrete  adenomyoma. 

H.  A.  K.  Sanitarium  No.  1872.     Path.  No.  8433. 
Uterine     myomata,     subperitoneal     and    in- 
terstitial   nodules,    adenomyoma    of    the    uter- 


SUBPERITONEAL    A.ND    ENTRALIGAMENTARY    ADENOMYOMATA      111 

in  e  walls;  discrete  adenomyoma  of  the  utero- 
ovarian     Ligament,    showing    Large    islands    of 

in  u  c  o  s  a ,  t  y  p  i  c  a  1  m  i  n  i  a  t  u  r  e  u  I  e  r  i  n  e  c  ;i  v  i  I  i  e  e 
<  Figs.  11  and  42). 

I).,  white,  married,  aged  fifty-one.     Admit  led  March  22,   L905. 

Died  April  1"),  1905.  Patient  has  always  been  a  frail  woman.  Since 
the  menopause  there  has  been  a  slight  vaginal  discharge.  She  has 
been  awTare  of  the  presence  of  an  abdominal  tumor  for  the  pasl  six 
months.  There  has  been  a  great  deal  of  pain  and  a  feeling  of  weigb.1 
in  the  abdomen.  She  apparently  had  an  attack  of  pelvic  peritonitis 
in  January.     Her  haemoglobin  is  50  per  cent. 

Operatio  n  . — Hystero-myomeetomy,  repair  of  the  perineum. 
The  patient  after  operation  was  exceedingly  nervous  and  had  a  great 
deal  of  pain.  On  the  fourth  day  she  was  as  bright  as  usual,  when 
she  suddenly  began  to  scream  and  became  unconscious  and  died  in 
a  very  short  time.  Embolism  was  thought  to  have  been  the  cause 
of  death.     Her  highest  post-operative  temperature  was  100°  F. 

Path.  No.  8433  . — The  specimen  consists  of  a  multi- 
nodular myomatous  uterus  which  has  been  amputated  through  the 
cervix.  It  is  14  cm.  in  length,  13  cm.  from  side  to  side,  and  perfectly 
smooth.  The  nodules  seen  on  the  outer  surface  vary  from  2  to  9  cm. 
in  diameter.  The  right  tube  and  ovary  are  normal.  The  left  tube 
presents  the  usual  appearance.  The  left  ovary  contains  what  ap- 
pears to  be  a  corpus-luteum  cyst,  3  cm.  in  diameter,  at  its  outer  pole. 
Perfectly  independent  from  the  uterus  and  attached  to  the  utero- 
Ovarian  ligament  on  the  left  side  is  a  myoma,  6  cm.  in  length,  4  cm. 
in  breadth,  and  3  cm.  in  thickness  (Fig.  41).  Projecting  slightly 
from  the  surface  are  a  subperitoneal  cyst,  1  cm.  in  diameter,  and 
numerous  smaller  ones. 

On  making  sections  of  the  nodule  projecting  from  the  left  utero- 
ovarian  ligament  we  find  in  the  lower  part  cystic  spaces  reaching 
1.5  cm.  in  diameter.  Sections  through  the  middle  portion  show 
cystic  spaces  1  mm.,  others  2  mm.,  and  some  4  mm.  in  diameter. 
Section  through  the  attachment  of  the  myoma  to  the  utero-ovarian 
ligament  reveals  a  cystic  space,  7  mm.  in  length  and  approximately 


142 


ADENOMYOMA    OF    THE    UTERUS 


3  mm.  broad.     It  has  a  definite  yellowish  lining  and  encloses  choco- 
late-colored contents.     Several  of  the  spaces  are  filled  with  a  brown- 


Fig.  41. — Subperitoneal  axd  ixterstitial  uterine  mtomata;  adexomyoma  of  the  body 
OF  THE  uterus.  Adbnomyoma  sprixgixg  from  the  left  utero-oyariax  ligamext. 
(f  natural  size.) 

Gyn.-Path.  Xo.  843  3.  The  uterus  is  the  seat  of  subperitoneal  and  interstitial 
myomata.  Xear  the  cerYix  on  the  anterior  surface  is  a  small  cyst.  The  left  tube  is  normal.  The 
left  ovary  contains  a  small  corpus-luteum  cyst.  b.  Projecting  from  the  left  utero-OYarian  ligament 
is  a  subperitoneal  myoma,  a.  This  has  a  few  cysts  projecting  from  its  surface  as  indicated.  On 
section  this  nodule  was  found  to  contain  cysts.  1  cm. or  more  in  diameter,  lined  with  mucosa  and 
filled  with  chocolate-colored  blood,  miniature  uterine  caA'ities.  also  whitish  yellow  areas,  and 
normal  uterine  mucosa.     (See  Fig.  42. ) 

It  may  be  of  interest  to  know  that  the  uterine  mucosa  extended  into  the  myomatous  uterine 
walls. 

ish  putty-like  material  and  have  yellowish  margins.     The  ovary 
contains  a  cystadenoma. 

On  section  the  uterine  cavitv  is  7  cm.  in  length  and  the  mucosa 


SI   BPERITONEAL    AND    [NTRALIGAMENTART?    AJ>ENOMYOMATA      143 

in  places  reaches  9  nun.  in  thickness.  Some  of  the  glands  are  dilated. 
The  muscular  layers  of  the  uterus  present  a  rather  coarse,  striated 
appearance. 

On  his  to  1  o  g  ical  ex  a  m  inal  i  o  n  the  cervical  mucosa 
is  perfectly  normal  in  many  places;  al  other  points,  however,  there 
is  a  greal  deal  of  gland  dilatation,  and  there  is  a  large  thin-walled  cysl 
lined  with  one  layer  of  fiat  epithelium  and  filled  with  coagulated  ma- 
terial presenting  a  picture  almost  identical  with  one  of  the  thyroid. 
This  appearance  is  due  to  massive  dilatation  of  some  of  the  cervical 
glands.  We  also  have  small  cysts  presenting  a  sieve-like  appearance. 
This  picture  is  due  to  a  polypoid  formation  at  certain  points.  The 
uterine  mucosa  in  places  reaches  11  mm.  in  thickness.  In  mam- 
places  it  has  been  most  imperfectly  preserved.  The  surface,  how- 
ever, is  practically  intact.  The  glands  are  ribbon-like  owing  to 
degeneration,  and  we  are  unable  to  tell  why  the  mucosa  was  so 
thickened,  on  account  of  this  degeneration.  There  is,  however,  not 
the  slightest  evidence  of  any  malignancy.  The  underlying  muscle 
is  somewhat  dense,  and  in  it  near  the  mucosa  we  find  isolated  glands 
which  have  extended  down  from  the  surface.  In  one  of  the  sections 
an  island  of  mucosa  with  the  characteristic  stroma  surrounding  it 
can  be  seen  at  least  3  mm.  from  the  mucosa.  The  g  r  o  w  t  h  is 
a  definite  adeno  m  y  o  m  a  ,  with  the  g  1  a  n  d  s  c  o  m  - 
i  n  g  from  the  mucosa.  Sections  from  the  nodule  spring- 
ing from  the  left  utero-ovarian  ligament  show  a  most  instructive 
picture  (Fig.  42).  A  transverse  section  over  the  point  of  attach- 
ment of  the  utero-ovarian  ligament,  where  we  noticed  several  spaces. 
shows  that  these  are  lined  with  one  layer  of  cylindrical  epithelium. 
This  at  times  projects  out  as  little  tufts  and  beneath  it.  and  sepa- 
rating it  from  the  muscle,  is  a  certain  amount  of  characteristic 
stroma.  In  other  portions  of  this  nodule  we  have  little  gland-like 
spaces  extending  out  into  this  main  cavity.  Still  other  sections 
contain  glands  resembling  uterine  glands  in  every  way.  These  are 
separated  from  the  muscle  by  a  characteristic  stroma.  Sections 
from  the  centre  of  the  nodule  show  a  most  interesting  picture. 
We  have   cyst-like  spates  similar   to    those   above   described,   and 


144  ADENOMYOMA    OF   THE    UTERUS 

likewise  miniature  uterine  cavities.  Some  of  the  glands  are 
dilated.  In  the  vicinity  is  a  group  of  glands  similar  in 
appearance.  We  have  here  subperitoneal  and  interstitial  uterine 
myomata ;  marked  thickening  of  the  endometrium  with  definite  ade- 
nomyomatous  formation,  and  adenomyoma  of  the  left  utero-ovarian 
ligament.     This  myoma  is   diffuse   in  character,  contains  cyst-like 


Fig.  42. — Cross-section  through  a  pedunculated  subperitoneal  adenomyoma.     (4  diam- 
eters.) 

Gyn.-Path.  No.  843  3.  The  picture  represents  a  cross-section  through  the  subperitoneal 
adenomyoma  a  in  figure  41.  Scattered  throughout  the  tissue  are  isolated  cystic  and  dilated 
glands  (a) .  Near  the  centre  are  two  large  areas  of  typical  uterine  mucosa ;  one  of  these  contains  a 
miniature  uterine  cavity  as  indicated  at  b.  The  darker  tissue  as  seen  at  c  indicates  the  myomatous 
muscle.     This  stands  out  in  sharp  contrast  to  the  paler  staining  stroma  as  indicated  at  d. 

spaces  and  miniature  uterine  cavities.  In  other  areas  it  is  a  typical 
adenomyoma,  differing  in  no  way  from  an  adenomyoma  with  the 
glands  originating  from  the  mucosa.  The  mucosa  in  this  case  shows 
a  definite  adenomyomatous  tendency  as  it  extends  into  the  under- 
lying muscle.  It  seems  reasonably  probable  that  the  adenomyoma 
of  the  utero-ovarian  ligament  at  one  time  lay  next  to  the  uterine 
mucosa,  and  that  it  was  gradually  pushed  outward  until  it  became 


SUBPERITONEAL   AM)    [NTRALIGAMENTARY    ADENOMYOMATA       L45 

subperitonea]  and  bo  all  intent  and  purpose  lost  its  continuity  with 
the  uterus. 

Gyn.  No.  12,036.     Path.  No.  8579. 

S  u  I)  p  eri  1  0  o  e  a  l  a  n  d  interstitial  ui  e  r  i  d  e 
m  y  0  m  a  t  a  ,    0  n  e   o  f    \v  h  i  <•  h    w  a  s    a  11    a  <1  e  n  0  m  y  0  m  a  . 

M.  V.,  aged  forty-six,  white,  married.  Admitted  April  8,  L905; 
discharged  May  22,  1905.  Complaint:  Right  inguinal  hernia; 
descensus  and  retroposition  of  the  myomatous  uterus,  ulceration  of 
the  vagina.  One  aunt  has  cancer.  The  menses  commenced  at 
eighteen.  The  menopause  occurred  in  November,  1904.  The 
patient  has  been  married  fourteen  years  and  has  never  been  pregnant . 
The  inguinal  hernia  was  noticed  two  years  ago.  In  the  posterior 
vagina*!  wall  there  is  a  granulating  area  about  8  mm.  in  diameter 
just  two  inches  from  the  outlet. 

On  opening  the  abdomen  a  small  flat  myoma  was  found  in  the 
posterior  wall  near  the  cervix.  This  was  removed,  and  some  small 
interstitial  nodules  were  shelled  out.  The  hernia  was  repaired  and 
the  patient  made  a  good  recovery.  The  highest  post-operative 
temperature  was  99°  F. 

Path.  No.  8579  . — The  larger  specimen  consists  of  a 
myoma,  4  by  2  by  2  cm.  This  is  partly  subperitoneal.  There  are 
also  small  interstitial  nodules.  On  section  numerous  cyst-like 
spares  are  to  be  made  out  in  the  myoma,  which  presents  a  coarse 
striation  and  suggests  adenomyoma.  Throughout  this  myoma 
definite  spaces  can  be  seen.  These  are  lined  with  a  single  layer  of 
columnar  epithelium.  At  one  or  two  points  the  glands  can  be  traced 
for  a  distance  of  5  mm.  As  the  uterine  cavity  was  not  opened,  of 
course  it  is  impossible  for  us  to  trace  the  continuity  with  the  mucosa. 

D  i  a  g  n  o  s  i  s  . — Subperitoneal  adenomyoma  :  small  inter- 
stitial nodules. 

INTRALIGAMENTARY  ADENOMYOMATA 

Case  8780  is  a  very  good  example  of  this  variety,  although  the 

growth  also  projects  into  the  uterine  cavity.     As  seen  in  Fig.    (•">. 

10 


146  ADENOMYOMA    OF    THE    UTERUS 

it  is  a  goodly  sized  tumor  which  extends  far  out  into  the  right  broad 
ligament,  the  folds  of  which  it  widely  separates.  Where  it  becomes 
submucous,  its  character  is  more  evident.  It  is  covered  over  with 
mucosa,  but  presents  a  rather  lobulated  appearance  owing  to  the 
presence  of  cysts  of  varying  size  projecting  inward  from  the  growth. 
From  the  soft  character  of  the  growth  sarcoma  was  suspected  at  the 
time  of  operation,  particularly  as  the  mucosa  was  intact  and  showed 
no  evidence  of  a  carcinomatous  process.  Fig.  44  is  a  cross-section 
of  the  opened  uterus,  taken  near  the  fundus.  The  growth  is  seen  to 
be  a  myoma  covered  externally  with  a  layer  of  normal  muscle  and 
internally  with  mucosa.  Traversing  it  everywhere  are  large  and 
small  irregular  cyst  cavities.  On  histological  examination  some  of 
these  cavities  were  found  to  communicate  with  one  another.  They 
were  in  part  empty,  in  part  filled  with  coagulated  serum  or  blood. 
They  had  a  smooth  inner  lining  resembling  mucosa.  This  in  places 
was  of  appreciable  thickness.  The  microscopic  examination  re- 
vealed the  fact  that  some  of  them  resembled  miniature  uterine  cavi- 
ties, having  an  inner  lining  of  cjdindrical  epithelium  beneath  which 
were  typical  uterine  glands  embedded  in  their  usual  stroma.  At  c 
in  Fig.  45  we  even  noted  hypertrophy  of  some  of  the  glands  so  char- 
acteristic of  the  uterine  mucosa  in  some  cases.  Others  of  the  cysts 
had  no  glands,  merely  a  row  of  cylindrical  cells  separating  them 
from  the  myomatous  muscle.  The  uterine  mucosa  was  normal  and 
no  connection  was  found  between  the  adenomyoma  and  the  mucosa 
lining  the  uterine  cavity. 

Kroenig1  reports  a  very  interesting  instance  of  a  cystic  adeno- 
myoma springing  from  the  posterior  wall  of  the  uterus  and  extend- 
ing backward  beneath  the  peritoneum  of  Douglas'  pouch.  It  con- 
sisted of  one  large,  thin-walled  cyst  containing  a  litre  of  brownish- 
red  fluid,  and  of  a  more  solid  portion  consisting  of  about  thirty  small 
spaces  so  arranged  that  the}7  resembled  a  honeycomb.  The  walls 
of  the  large  cyst,  especially  of  that  portion  lying  free  in  the  abdominal 

1  Kroenig,  B.:  Ein  retroperitoneal  gelegenes  voluminoses  Polycystom  entstanden 
aus  Resten  des  Wolff'sehen  Korpers.  Beitrage  zur  Geburtshulfe  und  Gynak.,  1901, 
Bd.  iv,  p.  61. 


SUBPERITONEAL   AM)    I  \TK.\  l.KJA.M  K\T\i;  Y    ADENOMYOMATA       117 

Cavity,  were  very  thin,  in  places  measuring  scarcely  more  than  I  mm. 
The  cyst  walls  were  composed  of  fibrous  tissue  and  of  a  varying 
amount  of  muscle.  The  inner  surface  was  in  places  lined  with  cylin- 
drical ciliated  epithelium.  The  more  solid  portion  of  the  tumor  was 
a  typical  cystic  adenomyoma  which,  as  Kroenig  says,  in  form,  in  ar- 
rangement of  glands  and  in  the  cystic  spaces,  corresponded  in  prac- 
tically all  points  with  the  adenomyomata  of  von  Recklinghausen. 
There  were  definite  "roups of  "lands  surrounded  by  the  character^  lc 
stroma.  Kroenig  thinks  that  the  tumor  originated  in  the  uterine 
wall,  and  was  later  pushed  out  into  the  connective  tissue  of  Douglas5 
pouch. 

Hartz1  observed  a  similar  case  in  Sanger's  clinic. 

While  considering  intraligamentary  adenomyomata  we  must  not 
omit  the  two  interesting  cases  reported  by  Breus2  in  1894.  In  his 
(  ase  1  a  large,  partly  cystic  and  partly  solid  myoma  was  met  with  in 
the  right  broad  ligament.  On  removal  it  was  found  to  be  made  up 
of  a  framewrork  of  myomatous  tissue  containing  several  large  cysts. 
Their  dimensions  may  be  imagined  from  the  fact  that  7  litres  of 
thick  grayish-brown  fluid  were  evacuated  prior  to  the  removal  of 
the  tumor.  The  cyst  cavities  had  smooth  inner  surfaces  and  ap- 
peared to  be  lined  with  mucous  membrane.  In  the  more  solid  por- 
tions, definite  myomatous  nodules  as  large  as  a  fist  were  found. 
Such  nodules  on  section  contained  large,  smooth-walled  cavities, 
which  were  filled  with  either  light  or  dark  brown,  friable  or  thick. 
fluid  contents  similar  to  those  of  the  large  cyst.  The  tumor  proved 
to  be  a  typical  myoma.  The  large  cyst  was  lined  with  a  single  layer 
of  cylindrical  ciliated  epithelium.  Breus  thought  that  the  tumor 
was  of  uterine  origin  and  that  it  had  spread  out  between  the  folds  of 
the  broad  ligament. 

Breus'  Case  2  is  even  more  instructive  than  the  first.     The  patient 
was  fifty-one  years  of  age.     There  was  a  tumor  tin1  size  of  a  child's 

1  Hartz,  A.:  Neuere  Arbeiten  iiber  die  mesonephrischen  Geschwulste.  Monats- 
schrift  f.  Geburtshiilfe  und  Gynakologie,  Bd.  xiii. 

2  Breus,  Carl:  I'cber  wahre  opithelfuhrende  Cystenbildung  in  Uterusmyomen. 
Leipzig,  1S94. 


148  ADEXOMYOMA    OF    THE    UTERUS 

head  springing  from  the  posterior  surface  of  the  uterus  and  covered 
by  the  peritoneum  of  Douglas'  sac  and  the  left  broad  ligament.  The 
tumor  on  its  upper  and  posterior  surface  was  hard.  On  section  it 
was  seen  to  be  composed  of  myomatous  tissue,  but  the  central  portion 
contained  several  cavities.  These  varied  from  a  pea  to  an  apple  in 
size  and  were  in  part  separated  from  one  another  by  thick  partitions. 
Several  of  them,  however,  communicated  one  with  the  other.  The 
cysts  had  smooth  inner  surfaces  and  were  filled  with  a  thick,  choco- 
late-brown fluid.  The  largest  cyst  communicated  directly  with  the 
uterine  cavity  by  a  funnel-shaped  opening  just  above  the  internal 
os.  The  cysts  were  lined  with  cylindrical,  ciliated  epithelium,  and 
where  the  large  cyst  communicated  with  the  uterine  cavity  the  sur- 
face epithelium  of  the  uterine  mucosa  was  directly  continuous  with 
that  of  the  cyst.  Breus  considered  the  tumor  as  a  subperitoneal 
and  intraligamentary  cystic  myoma  of  the  uterus. 

The  intraligamentary  cystic  adenomyomata  differ  in  no  way 
from  the  subperitoneal  growths  except  for  the  fact  that  they  spread 
out  between  the  folds  of  the  broad  ligament,  and  hence  offer  greater 
difficulty  in  removal.  All  of  the  tumors  consist  of  myomatous  tissue 
and  contain  characteristic  glands  and  stroma,  and  furthermore  all 
the  cysts  are  lined  with  cylindrical  and  usually  ciliated  epithelium. 
Particularly  instructive  is  Breus'  second  case,  in  which  the  epithe- 
lium of  the  uterine  mucosa  was  directly  continuous  with  that  of  the 
large  cyst.  Nearly  all  of  the  intraligamentary  cysts  are  also  par- 
tially filled  with  blood. 

It  will  be  noted  from  the  foregoing  cases  that  wherever  the 
subperitoneal  or  intraligamentary  adenomyomata  reach  any  size 
they  become  cystic.  In  some  the  cysts  were  single,  but  they  were 
usually  multiple.  The  cyst  walls  were  made  up  of  myomatous 
tissue  and  their  inner  surfaces  were  lined  with  cylindrical  epithelium, 
on  which  the  cilia  were  usually  demonstrable.  The  cysts  almost 
without  exception  contained  a  chocolate-colored  or  bloody  fluid. 
In  the  solid  portion  of  the  tumor  tubular  glands  were  found,  sur- 
rounded by  a  definite  stroma;  in  short,  a  definite  mucosa,  identical 
with  that  normally  found  lining  the  uterine  cavit3r,  was  present. 


SUBPERITONEAL    WD    [NTRALIGAMENTART    ADENOMYOMATA       L49 

Subperitoneal  adenomyomata  differ  in  do  way  from  t he*  diffuse 
uterine  myomata  save  for  the  fact  thai  they  become  cystic;  and 
this  difference  is  easily  explained  inasmuch  as  the  subperitoneal 
tumors  are  released  from  the  contracting  and  controlling  influence 
of  the  uterine  muscle.  Their  glands  are  occluded,  and  from  the  con- 
stant accumulation  of  the  epithelial  secretion  and  the  frequent 
hemorrhages,  which  undoubtedly  occur  at  the  menstrual  period, 
rapidly  become  larger.  It  will  be  noted  thai  the  Large  cysts  are 
invariably  found  where  the  least  amount  of  muscle  is  present. 

AN  INTRALIGAMENTARY  ADENOMYOMA  OF  THE  UTERUS 

Gyn.  Nos.  6855  and  8780.     Path.  No.  4966. 

I  n  t  rali  g  a  m  e  n  t  a  r  y  a  d  e  11  o  m  y  o  m  a  of  the 
uterus  exte  n  d  i  n  g  into  the  r  i  g  h  t  b  r  o  a  d  lig- 
ament and  also  becoming  submucous  (Figs.  4o. 
44,  and  4o).  G  1  a  n  d  h  ypertrophy  of  the  uteri  n  e 
mucosa,  slight  pelvic  adhesions.  Hysterec- 
tomy.     Recovery.     (See  page  160,  for  first  operation.  1 

A.  B.  W.,  aged  thirty-six,  white,  married.  Admitted  May  21; 
discharged  June  11,  1901.  Complaint:  Continuous  bleeding  from 
the  uterus  and  pain  in  the  right  lower  abdomen.  The  patient  has 
been  married  sixteen  years  and  has  had  three  children.  The  menses 
commenced  at  twelve,  and  w^ere  regular,  lasting  about  four  days. 
There  was  no  pain  and  the  flow  was  moderate. 

On  April  22,  1899,  a  vaginal  myomectomy  was  done,  a  sub- 
mucous adenomyoma  being  removed.  Before  this  operation  there 
had  been  a  slight  bloody  discharge  at  irregular  intervals.  Menstrua- 
tion was  normal  after  the  operation  until  five  years  ago.  when  the 
patient  began  to  have  continuous  profuse  bleeding  from  the  uterus 
and  pain  in  the  right  side.  She  was  curetted  two  or  three  times 
and  the  last  two  periods  were  normal.  For  the  past  two  or  three 
years  leucorrhcea  has  been  profuse.  At  times  there  has  been 
dysuria,  when  the  uterus  seemed  to  press  on  the  bladder.  On 
such  occasions  it  was  necessary  for  her  to  push  the  uterus  up 
before  she  could  urinate.     The  bowels  arc  constipated. 


150  ADENOMYOMA    OF   THE    UTERUS 

The  outlet  is  very  much  relaxed.  The  cervix  is  lacerated  and 
the  orifice  is  2  cm.  in  diameter,  slightly  bluish.  The  uterus  forms  a 
mass  filling  two-thirds  of  the  pelvis,  the  organ  being  about  the  size 
of  that  of  a  three  and  a  half  or  four  months'  pregnancy.  The  uterine 
cavity  is  13  cm.  long  and  is  displaced  somewhat  to  the  left. 

Operation,  May  22,  1901.  Panhysterectomy.  Suspension 
of  the  corners  of  the  vagina  to  the  round,  infundibulo-pelvic  and 
sacro-uterine  ligaments  on  either  side.  On  opening  the  abdominal 
cavity  the  appearance  strongly  suggested  a  sarcoma  involving  the 
right  uterine  walls  and  extending  into  the  right  broad  ligament. 
The  right  tube  and  ovary  were  adherent  to  the  pelvic  floor.  The 
left  tube  and  ovary  were  normal  except  for  slight  ovarian  adhe- 
sions. 

Gyn.-Path.  No.  4966  . — The  specimen  consists  of  an 
enlarged  uterus  with  the  tubes  and  ovaries  intact.  The  uterus  is 
somewhat  pear-shaped  and  irregular  in  outline.  It  is  14  cm.  in 
length,  13  cm.  in  breadth,  and  12  cm.  in  its  antero-posterior  diameters. 
Anteriorly  it  is  smooth  and  glistening;  posteriorly,  much  injected 
and  covered  with  a  few  recent  adhesions.  The  increase  in  the  size  of 
the  uterus  is  in  great  part  due  to  a  tumor  occupying  the  right  side  of 
the  body  and  extending  out  into  the  folds  of  the  right  broad  liga- 
ment and  also  to  the  posterior  and  right  side.  This  tumor  is  ap- 
proximately 10  cm.  in  diameter,  is  exceedingly  soft,  and  feels  like 
a  cyst  with  the  walls  probably  5  mm.  thick.  On  opening  the  uterus 
the  external  os  is  found  to  be  2.5  cm.  in  diameter;  the  mucosa  of 
the  vaginal  portion  is  intact,  but  just  beneath  the  mucous  mem- 
brane are  a  few  Nabothian  follicles.  The  cervical  canal  is  much 
dilated  and  is  3.5  cm.  in  length.  Its  mucosa  is  intact,  but  apparently 
somewhat  thickened  (Fig.  43).  The  cavity  of  the  uterus  is  8  cm. 
in  length  and  averages  5  mm.  in  breadth  in  its  middle  portion.  The 
uterine  walls  vary  from  2  to  3  cm.  in  thickness.  Projecting  into 
the  uterine  cavity  and  apparently  continuous  with  the  mass  on  the 
right  side  is  a  somewhat  globular  tumor,  7  cm.  in  length  and  6  cm. 
in  breadth.  This  has  a  very  broad  basal  attachment,  presents  a 
fairly  lobulated   surface,  and   is  everywhere  covered  with  mucosa, 


SUBPERITONEAL    AM)    [NTRALIGAMENTARY    ADENOMYOMATVA       1 


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152 


ADENOMYOMA    OF    THE    UTERUS 


which,  however,  is  somewhat  thinned  out.  On  pressure  the  sub- 
mucous tumor  gives  the  impression  of  being  cystic.  The  uterine 
mucosa  averages  2  mm.  in  thickness,  is  smooth  and  grayish- white  in 
appearance. 

Right  side:    The  tube  is  12  cm.  in  length  and  near  the  uterus 
averages  5  mm.  in  diameter;    it  is  free  from  adhesions.     The  fim- 


FlG.  44. A  CYSTIC   INTRALIGAMENTARY  AND  PARTLY    SUBMUCOUS    ADENOMYOMA    OF  THE    UTERUS. 

(Natural  size.) 

Gyn.-Path.  No.  4966.  The  drawing  illustrates  a  section  through  Fig.  43  between 
b  and  b'.  a  is  a  cross-section  of  the  left  tube,  b  is  a  small  portion  of  the  uterine  cavity,  c  is  the 
submucous  portion  of  the  cystic  adenomyoma  and  d  its  intraligamentary  pole,  e  is  one  of  the 
irregular  cyst-like  spaces  with  a  smooth  velvety  inner  lining  resembling  mucosa.  Just  above  it  is  a 
similar  but  smaller  one.  The  other  spaces,  as  indicated  by  /,  also  irregular  in  outline,  are  filled 
with  glistening  coagulated  contents  which  have  not  been  removed.  The  coagulation,  of  course, 
was  due  to  the  hardening  fluid,  g  is  the  characteristic  myomatous  tissue.  The  outline  of  the 
myomatous  growth  is  well  defined,  but  notwithstanding  this  fact  the  tumor  merges  gradually 
into  the  normal  muscle. 


briated  extremity  is  occluded  and  covered  with  adhesions.  The  tube 
in  the  vicinity  of  its  outer  end  is  8  mm.  in  diameter  and  very  firm. 
Situated  just  beneath  the  tube  and  within  3  cm.  of  its  fimbriated  end 
is  a  firm  bean-shaped  area  1.2  cm.  in  length.  On  section  it  is  found 
to  be  a  cyst-like  space  lined  with  smooth  mucosa  and  filled  with  a 
brownish-yellow  material,  partly  soft,  but  at  one  point  evidently 
organized  and  adherent  to  the  cyst  wall.     The  ovary  measures  3  by 


-i   BPERITONEAL    WD    [NTRALIGAMENTART    ADENOMYOMATA      LOd 

2.5  by  I  cm.  and  is  partially  enveloped  in  adhesions  and  adherent 
to  the  t  ube. 

Lefl  side:  The  tube  is  1 1  cm.  in  Length,  and  throughout  its  entire 
extent  is  very  small,  averaging  not  more  than  3  or  1  nun.  in  diameter. 
The  fimbriated  extremity  is  patent,  bul  the  tube  near  its  outer  end 
is  attached  to  the  ovary  by  fan-like  adhesions.  The  ovary  measures 
1  by  3.5  by  2  cm.  It  contains  a  recent  corpus  luteum  and  apart 
from  the  tubal  adhesions  is  free. 

On  making  a  transverse  section  of  the  uterus  after  the  specimen 
has  I  .ecu  hardened  in  Midler's  fluid  it  is  found  that  the  tumor  occupy- 
ing the  right  side  and  extending  out  into  the  right  broad  ligamenl 
is  directly  continuous  with  the  submucous  nodule  which  occupies 
the  uterine  cavity.  In  other  words,  we  have  an  interstitial  myoma, 
which  on  its  inner  side  has  become  submucous  and  on  its  outer  side 
extends  into  the  broad  ligament.  This  nodule  is  fully  8  cm.  in 
diameter  and  is  sharply  differentiated  from  the  uterine  muscle, 
which  on  its  outer  side  forms  a  covering  5  mm.  in  thickness.  The 
myoma  is  irregular  in  contour  and  in  places  presents  the  usual  pic- 
ture. It  contains  at  least  eight  medium  sized  cyst-like  spaces,  the 
largest  reaching  2.5  cm.  in  length  and  1  cm.  in  breadth  (Fig.  44  . 
Each  of  these  has  a  smooth  lining  membrane,  waxy  in  appearance 
and  varying  from  .5  to  1  mm.  in  thickness.  The  cavities  of  nearly 
all  of  these  spaces  are  filled  with  a  jelly-like  material,  evidently  coag- 
ulated serum.  One  contains  coagulated  blood.  The  cyst-like  spaces 
are  more  abundant  in  the  central  portions  of  the  growth  and  toward 
the  uterine  cavity.  They  are  similar  to  those  noted  beneath  the 
surface  of  the  submucous  myoma. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — The  mucosa  lining 
the  vaginal  portion  of  the  cervix  and  the  cervical  canal  is  normal. 
That  covering  the  anterior  portion  of  the  uterine  cavity  is  thickened; 
the  surface  epithelium  is  somewhat  flattened  and  its  glands  show 
marked  hypertrophy.  The  stroma  between  the  glands  shows  con- 
siderable small  round-cell  infiltration  and  is  very  lax.  In  the  deeper 
portions  it  is  unaltered.  The  mucosa  covering  the  submucous 
portion  of  the  tumor  is  somewhat   thinned  out.      The  surface  epi- 


154 


ADENOMYOMA    OF   THE    UTERUS 


thelium  is  intact,  but  the  glands  show  slight  hypertrophy.  One  of 
the  cysts,  1.5  cm.  in  length,  .5  cm.  in  breadth,  and  situated  directly 
beneath  the  mucosa,  has  a  lining  in  no  way  distinguishable  from 
uterine  mucous  membrane  (Fig.  45).  Its  inner  surface  is  covered 
with  one  layer  of  cylindrical  and,  in  places,  slightly  flattened  epithe- 
lium.     Beneath    this    the   characteristic  stroma   of  the  mucosa  is 


3'!?^. '  '- 


Fig.  45. — The  submucous  portion  of  a  cystic  adenomyoma  op  the  uterus.     (5  diameters.) 

Gyn.-Path.  No.  4966.  The  section  is  from  the  submucous  myoma  seen  in  Figs. 
43  and  44.  a  represents  the  uterine  mucosa,  which  has  an  intact  surface  epithelium  and  per- 
fectly normal  uterine  glands.  The  stroma  of  the  mucosa  is  rarefied  but  normal.  A  is  one  of  the 
cyst-like  spaces.  At  some  points  it  is  lined  with  a  layer  of  cylindrical  epithelium  lying  directly  on 
the  muscle.  At  other  points  this  is  separated  from  it  by  a  small  amount  of  stroma  similar  to  that 
of  the  uterine  mucosa.  While  in  some  places,  as  at  b,  there  are  definite  uterine  glands  beneath  the 
epithelial  lining,  at  c  we  have  a  uterine  mucosa  equally  as  thick  as  that  covering  the  surface  of  the 
submucous  myoma  and  consisting  of  a  typical  gland  hypertrophy.  B,  C,  D  and  E  are  other  cyst- 
like spaces  lined  with  cylindrical  epithelium.  A  and  B  are  evidently  one  and  the  same  cavity, 
communicating  as  they  do  with  one  another  by  the  bar  d  consisting  of  the  characteristic  stroma  of 
the  mucosa  and  containing  two  small  glands. 

found,  and  scattered  throughout  the  stroma  are  normal  or  hyper- 
trophied  glands  precisely  similar  to  those  noted  in  the  mucosa 
lining  the  uterine  cavity.  Some  of  the  cyst  spaces,  which  are 
rather  small,  are  lined  with  a  layer  of  epithelium  closely  resembling 
that  lining  the  uterine  cavity.  In  a  few  places  the  nuclei  of  the 
epithelial  cells  are  slightly  drawn  out  and  irregular.  The  myo- 
matous tissue  as  a  whole  presents  the  usual  appearance.     It  has 


SUBPERITONEAL   AM)    [NTRALIGAMENTAR?    ADENOMYOMATA      L55 

scattered  bhroughoul  it,  however,  many  small  round  cells,  but  prac- 
tically no  polymorphonuclear  leucocyte-.  The  tubes  and  ovaries 
offer  nothing  of  interest . 

We  have,  then,  in  this  case  a  rather  large  and  sharply  defined 
myoma  situated  in  the  right  uterine  wall.  This  contains  large  and 
small  irregular  spaces  lined  with  mucous  membrane  identical  with  thai 
of  the  uterine  mucosa.  This  myoma  on  its  inner  side  has  become 
submucous  and  its  cyst-like  spaces  are  seen  projecting  into  the 
uterine  cavity  and  lying  just  beneath  the  mucous  membrane. 

Diagnosis  :  Adenomyoma  of  the  uterus  extending  into 
the  right  broad  ligament  and  also  becoming  submucous.  (Hand 
hypertrophy  of  the  uterine  mucosa,  slight  pelvic  adhesions. 


CHAPTER  VI 
SUBMUCOUS  ADENOMYOMATA 

These  are  certainly  not  very  common.  We  have  already  dis- 
cussed Case  8780  (Fig.  43,  p.  151)  under  the  heading  of  intraliga- 
mentary  adenomyoma,  but  fully  one-third  of  the  growth  is  sub- 
mucous, projecting  into  and  filling  the  uterine  cavity  from  cervix 
to  fundus.  The  surface  is  smooth  but  lobulated,  on  account  of  the 
underlying  cysts  which  project  toward  the  uterine  cavity.  As  was 
said  elsewhere,  the  growth  was  a  typical  adenomyoma  and  the  cyst 
spaces  were  lined  with  cylindrical  ciliated  epithelium.  Case  5973 
offers  a  very  good  illustration  of  a  small  submucous  adenomyoma. 
The  mucosa  over  the  nodule  has  to  a  great  extent  disappeared,  but 
here  and  there  a  gland  is  still  visible.  The  growth  is  essentially  a 
myoma.  It  contains  three  definite  bunches  of  glands  resembling 
uterine  glands  and  surrounded  by  the  typical  stroma  of  the  mucosa 
(Fig.  46).  There  are  also  a  few  isolated  glands,  some  surrounded 
by  stroma,  others  lying  in  direct  contact  with  the  muscle.  Near 
the  free  surface  is  a  cystic  gland.  In  this  case  there  were  other 
myoma ta,  necessitating  the  subsequent  hysterectomy. 

In  Case  6855  the  submucous  nodule  contains  a  few  small  uterine 
glands.  In  Case  10,872  the  myoma  contains  three  cystic  spaces, 
each  1  cm.  in  diameter  and  with  a  smooth  lining,  which  on  histo- 
logical  examination  is  seen  to  consist  of  one  layer  of  columnar  epithe- 
lium. In  Case  10,314  (Fig.  47,  p.  162)  we  have  a  typical  example 
of  a  submucous  myoma  containing  collapsed  and  dilated  spaces 
lined  with  a  definite  mucosa.  Some  of  these  cavities  are  filled  with 
chocolate-colored  contents. 

On  histological  examination  they  are  found  to  be  miniature 
uterine  cavities.  In  this  case  the  uterine  mucosa  can  be  followed 
directly  into  the  myoma. 

In  1896,  when  reporting  two  cases  of   diffuse  adenomyoma  of 

156 


SUBM1  C01  B    ADENOMYOM A'l  \  \.>t 

the  uterus,1  attention  was  directed  to  cases  of  submucous  adeno- 
myomata  reported  by  Diesterweu  and  Schatz.2  In  Diesterweg's 
rase  a  nodule  the  size  of  a  hen's  egg  presented  al  the  external  os. 
Its  surface  was  somewhat  eroded;  it  was  attached  above  the  in- 
ternal OS  and  projected  downward  by  a  pedicle  an  inch  in  thickness. 
The  nodule  was  composed  of  myomatous  tissue,  and  in  the  centre 
was  a  large  cavity  lined  with  mucosa  and  traversed  by  numerous 
small  depressions,  producing  an  appearance  suggestive  of  a  ventricle. 
There  was  a  smaller  cavity  the  size  of  a  cherry.  These  cysts  were 
lined  with  cylindrical  ciliated  epithelium  and  filled  with  brownish- 
black  blood.  Two  years  later,  after  the  administration  of  ergotin, 
a  submucous  myoma,  9  by  7  by  6  cm.,  was  expelled.  This  con- 
tained a  cyst  the  size  of  a  walnut.  The  cyst  was  lined  with  cylin- 
drical ciliated  epithelium  and  filled  with  blood. 

In  Schatz's  case  the  uterus  was  16  cm.  long,  8.5  cm.  in  diameter, 
and  its  walls  varied  from  2  to  2.5  cm.  in  thickness.  The  uterine 
cavity  contained  five  rows  of  broad-based  polypi.  Each  row  con- 
sisted of  from  two  to  six  polypi.  Between  the  rows  were  deep  de- 
pressions. The  polypi  pointed  toward  the  internal  os  and  varied 
from  a  pea  to  a  hen's  egg  in  size.  The  uterine  cavity  was  completely 
filled  with  them.  On  section  the  polypi  were  found  to  have  a  rich 
blood-supply  and  in  several  places  bundles  of  muscle  fibres  could  1  e 
seen  extending  into  them  and  reaching  almost  to  the  free  surface. 
Where  the  muscular  elements  predominated,  the  polypi  were  firm. 
Scattered  throughout  the  uterine  wall  were  small  myomata  which 
were  not  easily  shelled  out.  In  the  myomata  near  the  peritoneal 
surface  no  cysts  were  to  be  seen,  but  in  those  near  the  uterine  cavity 
and  also  in  the  muscle  they  were  present.  The  outer  portions  of 
the  uterine  wall  were  entirely  free  from  cysts.     The  polypi  consisted 

1  Cullen,  Thomas  S. :  Ailcnonivonia  Uteri  Diffusum  Benignum.  Johns  Hopkins 
Hospital  Reports,  1896,  vol.  vi 

2  Diesterweg:  Ein  Fall  von  Cystofibroma  uteri  verum.     Zeitschr.  f.  Geb.  u.  Gyn., 

lss.">.  Bd.  ix,S.  191.  Schatz:  Ein  fall  von  Fibro-adenome  cysticura  diffusum  et 
polyposum  corporis  el  colli  uteri.     Arch.  f.  Gyn.,  1884,  Bd.  wii.  S.  456. 


158  ADENOMYOMA  OF  THE  UTERUS 

of  spindle-shaped  cells,  and  scattered  throughout  them  were  gland- 
like cavities  lined  with  high  cylindrical  epithelium. 

It  would  appear  that  in  these  cases  there  had  been  a  diffuse 
adenomyoma  and  that  the  uterus  was  trying  to  free  itself  of  the  new 
growth  in  the  same  manner  in  which  it  extrudes  ordinary  myomata. 
A  polypoid  condition  had  naturally  resulted. 

Remembering  the  diffuse  adenomyomata  of  the  uterus  and  subse- 
quent extension  of  the  growth  to  the  outer  surfaces,  with  the  forma- 
tion of  subperitoneal  or  intraligamentary  cystic  adenomyomata,  it 
is  easily  understood  that  portions  of  the  growth,  at  least,  are  forced 
inward  and  become  submucous.  In  the  submucous  adenomyomata 
we  do  not  generally  expect  much  cystic  dilatation  of  the  glands, 
since  the  growth  is  continually  subjected  to  the  uterine  pressure  from 
all  sides. 

CASES  OF  SUBMUCOUS  ADENOMYOMA  OF  THE  UTERUS 

Gyn.  No.  5973.     Path.  No.  2250. 

Submucous  adenomyoma  of  the  uterus  (Fig. 
46j .  Removal  per  vaginam.  Subsequent  hys- 
terectomy on  account  of  uterine  myomata. 
Recovery. 

S.  G.,  single,  aged  thirty-nine,  black.  Admitted  March  22,  1898; 
discharged  June  3,  1898.  Complaint:  continuous  bloody  vaginal 
discharge.  The  patient  had  one  miscarriage  twenty  years  ago. 
Her  menses  commenced  at  twelve  and  were  regular,  but  for  the  past 
two  years  the  flow  has  lasted  about  twice  as  long  as  heretofore. 
Since  December  there  has  been  an  almost  continuous  bloody  dis- 
charge, at  times  profuse. 

About  two  years  ago  the  patient  commenced  to  have  pain  in  the 
lower  abdomen.  This  pain  lasted  about  six  months.  For  the  last 
three  years  she  has  been  short  of  breath,  and  since  August,  1897, 
her  feet  have  been  swollen.  For  several  months  there  has  been  a 
profuse  yellowish  leucorrhoeal  discharge. 

First  operation,  March  24,  1898.  Myomectomy  per  vaginam; 
evacuation  of  a  pelvic  abscess.     A  polyp  was  removed  through  the 


SI   BM1  COUS    A.DENOMYOMATA 


159 


vagina.  The  uterine  cavity  at  this  time  varied  from  LO  to  12  cm. 
in  Length  and  in  the  posterior  wall  was  a  myoma.  The  pelvic 
abscess  was  opened  and  a  small  amount  of  necrotic  material  and  pus 
came  away. 

Second  operation,  April  27,  1899.  Kystero-myomectomy,  righl 
salpingo-oophorectomy.  There  were  general  intestinal  adhesions 
and  the  bladder  was  markedly  lifted  up.  A  right  tubo-ovarian  ab- 
scess was  removed    together  with   a   myomatous    uterus.     Conva- 


Fig.  46. — Submucous  adenomyoma  of  the  uterus.     (7  diameters. 

Gyn.-Path.    No.    2  2  50.     Nearly  all  trace  of  the  mucosa  formerly  covering   the 

growth  lias  disappeared.  Nevertheless,  some  of  the  stroma  remains  and  is  recognized  at  </. 
In  some  places  are  a  few  isolated  uterine  glands  (b).  The  growth  is  composed  chiefly  of  myomatous 
muscle  and  at  points  c  c  are  the  characteristic  islands  of  uterine  mucosa,  consisting  of  glands 
enveloped  in  the  usual  amount  of  stroma.  Scattered  here  and  there  throughout  the  growth  are 
isolated  glands,  some  surrounded  by,  others  devoid  of,  stroma.     <l  is  a  dilated  gland. 


lescence  was  uninterrupted  save  for  slight  swelling  of  the  legs,  not 
associated  with  any  pain  or  with  any  urinary  disturbances. 

The  temperature  at  the  first  operation  reached  102°  F.  on  the 
third  day,  but  was  normal  by  the  ninth  day.  After  the  second  opera- 
tion it  rose  to  101.4°  F.  on  the  second  day  and  remained  below 
100°  F.  after  the  sixth  day. 

Gyn.-Path.  No.  2  2  5  0  . — The  specimen  consists  of  a 
submucous  nodule  measuring  approximately  4.5  by  2.5  by  1.5  cm. 
Its  surface  is  roughened.     On   section   it    presents  the  usual   myo- 


160  ADENOMYOMA    OF    THE    UTERUS 

matous  appearance,  but  just  beneath  the  surface  at  one  point  is  a 
cystic  space  5  mm.  in  diameter. 

Histological  Examination  . — The  surface  of  the 
myoma  is  over  a  considerable  area  covered  with  thinned-out  mucosa 
without  any  surface  epithelium  (Fig.  46).  The  glands  are  few  in 
number,  are  small,  and  have  a  normal  epithelial  lining.  The  stroma 
of  the  mucosa  is  fairly  dense  and  near  the  surface  contains  numerous 
small  blood-vessels.  The  myomatous  tissue  presents  the  usual 
appearance,  but  here  and  there,  in  the  depth  of  the  tissue,  are  groups 
of  small  tubular  or  slightly  convoluted  glands  resembling  in  every 
particular  uterine  glands  and  surrounded  by  a  stroma  similar  to  that 
of  the  uterine  mucosa.  Occasionally  one  or  two  isolated  glands  are 
found  lying  in  direct  contact  with  the  muscle.  The  small  cystic 
space  noted  macroscopically  is  a  dilated  gland. 

Diagnosis  . — Submucous  adenomyoma  of  the  uterus. 

Gyn.  No.  6855.     Path.  No.  3107. 

Submucous  adenomyoma.  (See  page  149  for  the 
subsequent  hysterectomy.) 

A.  B.  W.,  white,  aged  thirty-four,  married.  Admitted  April  20, 
1899;  discharged  June  1,  1899.  The  patient  has  had  three  children, 
the  oldest  thirteen,  the  youngest  nine.  The  menstrual  history  is 
normal,  but  there  has  been  a  profuse  and  offensive  leucorrhcea  for 
the  last  month.  The  patient  has  had  prolapsus  since  the  birth  of 
her  first  child,  thirteen  years  ago.  One  year  ago  some  operation  was 
performed,  apparently  a  removal  of  a  submucous  nodule.  Six 
weeks  ago  the  patient  noticed  that  there  was  a  tumor  protruding 
from  the  cervix.  During  the  last  two  weeks  there  has  been  slight 
hemorrhage.  The  patient  feels  that  she  is  growing  weaker  and  has 
lost  flesh.  She  has  not  been  able  to  do  any  work  for  the  last  six 
weeks. 

Operation  . — A  vaginal  cyst,  measuring  3  by  2  cm., 
was  removed  from  the  left  side,  just  behind  the  hymen.  There  was 
a  myomatous  growth,  4  by  3.5  by  4  cm.,  protruding  from  the  cervix. 
This  was  drawn  well  down  and  ligated,  and  a  large  tubo-ovarian 


SUBMUCOUS  ADKXOMYO.M  ATA  1  <  1  1 

abscess  on  the  righ.1  side  was  opened  and  thoroughly  drained.  Con- 
valescence was  uninterrupted. 

Path.  X  o  .  3107. — The  specimen  consists  of  a  sub- 
mucous myoma  and  of  a  vaginal  cyst.  The  myoma  measures  1  by 
3  by  1.5  cm.,  is  irregular  in  shape  and  somewhat  discolored.  ( In 
section  it  is  hard  and  dense. 

Hist  o  1  o  g  i  c  a  1  E  x  a  m  i  n  a  t  i  o  n  . — The  myoma  pre- 
sents the  usual  appearance.  Blood-vessels  are  abundant  and,  as  a 
rule,  small.  In  one  section  the  protoplasm  appears  to  be  swollen, 
pale-staining,  and  has  somewhat  the  appearance  of  fibrous  tissue. 
At  another  part  of  the  tumor  gland-like  spaces  are  seen,  two  of  them 
being  in  close  proximity  to  each  other,  and  three  some  distance  away. 
They  are  lined  with  a  single  layer  of  cylindrical  epithelium.  The 
specimen  is  a  submucous  adenomyoma  in  which  the  gland  elements 
are  few  in  number. 

Gyn.  No.  10,314.     Path.  No.  6531. 

Double  v  a g  i  n  a  ;  double  cervix;  1  a  r  g  e  sub- 
m  ucous  a  d  eno  m  y  o  m  a  w  i  t  h  the  g  1  a  11  d  s  ori  g  i  - 
n  a  t  i  n  g  from  the  uterine  m  u  c  o  s  a  a  n  d  c  o  n  t  a  i  n  - 
i  n  g  q  uantities  of  miniature  uterine  cavities 
(Fig.  47). 

E.  K.,  white,  aged  fifty,  married.  Admitted  March  7.  1903; 
discharged  April  17,  1903.  Complaint:  uterine  hemorrhages.  Her 
father  died  of  dropsy;  her  mother  of  cardiac  failure.  She  had 
scarlet  fever  at  thirteen,  but  otherwise  was  healthy  until  the  present 
illness.  Her  menses  were  normal  until  ten  years  ago.  Since  then 
she  has  had  considerable  pain  at  her  periods,  which  came  on  at  ir- 
regular intervals,  from  two  to  five  weeks,  and  were  more  profuse 
than  usual.  She  has  been  married  twenty-one  years,  but  has  never 
been  pregnant.  For  two  years  the  periods  have  been  profuse. 
coming  on  every  two  to  three  weeks,  accompanied  by  much  pain. 
She  has  lost  18  or  20  pounds.  The  patient  is  fairly  well  nourished: 
the  haemoglobin  55  per  cent.     Fine  crackling  sounds  are  heard  over 

the  right  upper  back  and  lower  right  front.     On  vaginal  examination 

11 


162 


ADENOMYOMA    OF    THE    UTERUS 


a  double  vagina,  with  the  septum  extending  the  entire  length  of  the 
vault,  a  double  cervix  and  a  double  cervical  canal  were  discovered. 
There  was  a  submucous  myoma  within  the  uterus.  This  was  appar- 
ently the  size  of  a  goose's  egg. 

Operation  . — The  sep- 
tum was  first  removed  and  the 
myoma  brought  away  in  frag- 
ments. Her  highest  post-oper- 
ative temperature  was  100°  F. 
on  the  second  day.  On  the 
twenty -first  day  there  was  phle- 
bitis of  one  of  the  small  veins  in 
the  left  leg.  The  patient  was 
discharged  well  on  the  twenty- 
seventh  day. 

Path.  No.  6531.- 
The  specimen  consists  of  a 
large  mutilated  submucous  my- 
oma, measuring  approximately 
11  by  7  by  7  cm.  On  section 
it  presents  the  typical  myoma- 
tous appearance.  Scattered 
throughout  it,  however,  are  nu- 
merous irregular  islands  of  mu- 
cosa. At  other  points 
are  spaces  fully  8  mm. 
long  b  y  2  mm.  b  r  o  a  d  , 
lined  with  mucosa, 
which  almost  com- 
pletely fills  the  cav- 
ity (Fig.  47).  They  are 
easily  recognized  as 
miniature  uterine  cavities.  All  these  spaces  are 
dilated  and  are  filled  with  chocolate-colored  contents,  evidently 
old  menstrual  hemorrhages. 


Fig.  47. — Submucous  adenomyoma  of  the 
uterus,  the  myomatous  muscle  being 
riddled  with  miniature  uterine  cavi- 
TIES.     (Natural  size.) 

Gyn.-Path.  No.  65  3  1.  This  is  a 
longitudinal  section  of  the  mutilated  submucous 
myoma  which  was  associated  with  a  double 
vagina  and  a  double  cervix.  The  greater  part  of 
the  tissue  consists  of  myomatous  tissue,  diffuse 
in  character.  On  the  left  is  a  partial  covering  of 
normal  uterine  muscle  (a).  Scattered  every- 
where throughout  the  myomatous  tissue  are 
collapsed  and  dilated  miniature  uterine  cavities. 
b,  b,  are  collapsed  cavities,  lined  with  a  definite 
mucosa,  c  is  a  slightly  dilated  cavity  likewise 
lined  with  mucosa,  while  d  represents  a  miniature 
uterine  cavity  distended  with  blood.  These 
cavities  on  histological  examination  are  found,  as 
their  names  would  imply,  to  be  lined  with  typical 
uterine  mucosa. 


SUBMUCOUS    A.DENOMYOM  \  T  \  L63 

On  histological  examination  the  specimen  pre- 
sents a  typical  myomatous  appearance.  Scattered  throughoul  the 
muscle  are  miniature  uterine  cavities,  some  of  them  reaching  l  cm. 
in  length;  also  islands  of  perfectly  normal  uterine  mucosa.  The 
glands  lining  these  miniature  cavities,  and  also  forming  the  islands 
of  perfectly  normal  mucosa,  arc  accompanied  by  the  usual  stroma. 
Here  and  there  a  gland  is  dilated  or  has  a  cavity  filled  with  old  men- 
strual clots  which  have  become  partly  disorganized.  The  spaces 
contain  fragments  of  nuclei  and  polymorphonuclear  leucocyte-. 
while  surrounding  them  are  many  small  connective-tissue  cells,  some 
containing  granular  pigmeni  and  remnants  of  blood.  At  other  points 
the  blood  is  still  well  preserved.  At  some  points  are  spaces  fully 
2  nun.  in  length,  evidently  dilated  glands.  They  are  lined  with 
cylindrical  epithelium  resting  on  a  stroma  which  separates  them  from 
the  muscle.  The  uterine  mucosa  in  a  few  places  is  preserved.  0  v  e  r 
t  h  e  ni  y  o  m  a  here  and  there  one  is  able  to  trace 
the  uterine  mucosa  as  it  penetrates  into  t h e 
depth. 

We  have  in  this  case  a  typical  submucous  adenomyoma.  where 
we  are  able  to  show  that  the  gland  elements  are  derived  from  the 
normal  uterine  mucosa. 

Gyn.  No.  10,872.     Path.  No.  7076. 

S  u  b  m  u  c  o  u  s      a  d  e  n  o  111  y  o  m  a  . 

II.  D.,  single,  aged  thirty-three,  colored.  Admitted  November 
12,  1903;  discharged  December  11,  1903.  The  patient  complains 
of  a  watery  discharge  which  has  persisted  for  six  months.  This  has 
at  times  been  profuse.  The  patient  is  well  nourished,  but  her  hae- 
moglobin is  only  60  per  cent.  The  entire  vagina  is  tilled  with  a 
globular  mass  which  projects  from  the  cervical  canal.  This  tumor 
was  bisected  and  found  to  be  attached  by  a  small  pedicle  which  was 
tied  off.  Her  highest  post-operative  temperature  was  100.5°  F. 
When  she  left  the  hospital  her  haemoglobin  was  still  60  per  cent. 

V  a  t  h  .  No.  707  6  . — The  specimen  consists  of  a  bi- 
sected, considerably  mutilated  myoma  measuring  10  by  7  by  4  cm. 


164  ADENOMYOMA  OF  THE  UTERUS 

On  section  the  tumor  presents  the  usual  appearance  save  for  three 
cystic  spaces,  each  about  1  cm.  in  diameter,  and  filled  with  fluid. 
These  have  smooth  inner  linings. 

On  histological  examination  the  myoma  shows 
marked  richness  in  muscle  cells.  There  is  also  considerable  hyaline 
degeneration.  The  cyst  walls  are  lined  with  cylindrical  epithelium 
similar  to  that  of  the  uterine  mucosa. 

Diagnosis  . — Submucous   adenomyoma. 


CHAPTEE  VII 

CERVICAL  ADENOMYOMATA 

From  the  study  of  adenomyomata  of  the  body  of  the  uterus  we 
have  seen  that,  in  the  first  place,  there  is  a  diffuse  myomatous  thick- 
ening of  the  inner  muscular  walls  accompanied  by  a  down-growth 
of  the  normal  mucosa  into  this  diffuse  growth.  Portions  of  this 
adenomyoma  may  become  subperitoneal  or  intraligamentary,  and 
often  form  a  large  cystic  adenomyoma.  Portions  of  the  diffuse 
growth  were  also  found  to  project  into  the  uterine  cavity,  forming 
submucous  adenomyomata.  Should  an  adenomyoma  develop  in 
the  cervix,  we  would  expect  it,  judging  from  analogy,  to  consist  of 
cervical  glands  enclosed  in  a  tissue  made  up  of  myomatous  muscle 
and  the  dense  stroma  characteristic  of  the  cervical  mucosa.  In  Case 
3898  (Fig.  48)  we  found  a  small  myomatous  uterus,  in  which  rem- 
nants of  an  adenomyoma  were  present  along  the  outer  border  of  the 
cervix,  i.  e.}  near  the  broad  ligament  or  vaginal  attachment.  A 
glance  at  Fig.  49  shows  that  the  glands  in  this  small  growth  corre- 
spond to  those  of  the  body  of  the  uterus,  and  in  addition  they  are  sur- 
rounded by  the  usual  stroma  found  in  the  mucosa  above  the  internal 
os.  Landau  and  Pick1  report  a  case  in  which  the  cervical  canal  was 
entirely  obliterated  by  an  adenomyomatous  nodule  which  com- 
pletely shut  off  the  uterine  cavity  from  the  vagina.  In  this  case 
also  typical  uterine  glands  with  their  accompanying  stroma  were 
the  epithelial  elements  present. 

In  1896  when  reporting  two  typical  cases  of  diffuse  adenomyoma 
of  the  body  of  the  uterus"  I  described  an  adenomyoma  of  the  cervix 

1  Landau,  L.,  and  Pick.  I..:  Qeber  die  mesonephrische  Atresie  der  Miiller'schen 
Gauge,  zugleich  ein  Beitrag  zur  Lehre  von  den  mesonephrischen  Adenomyomen  des 
Weibes  und  zur  Klinik  der  Gynatresien.     Arch.  f.  Gynak.,  1901,  Bd.  Ixiv,  S.  98. 

2 Cullen,  Thomas  S.:  Adenomyoma  Uteri  Diffusum  Benignum.  Johns  Hopkins 
Hospital  Reports,  vol.  vi. 

L65 


166  ADENOMYOMA    OF   THE    UTERUS 

consisting  of  cervical  glands,  muscle,  and  a  moderate  amount  of 
fibrous  tissue.  This  finding  is  very  rare,  as  from  the  literature  I 
have  been  unable  to  glean  a  single  similar  case.  In  Fig.  23,  p.  77, 
a  round  submucous  nodule,  2.5  cm.  in  diameter,  is  seen  projecting 
from  the  cervix. 

On  histological  examination  the  outer  surface 
of  the  nodule  is  found  to  be  in  places  covered  with  cylindrical  epithe- 
lium. Scattered  everywhere  throughout  the  muscle  are  gland- 
like spaces  varying  from  a  pin-head  to  3  mm.  in  diameter.  These 
are  lined  with  a  single  layer  of  epithelium,  which  in  the  smaller 
glands  is  of  the  high  cylindrical  variety.  In  the  dilated  glands, 
however,  it  is  cuboidal  or  has  become  almost  flat.  The  cell  pro- 
toplasm takes  the  hematoxylin  stain,  as  is  so  characteristic  of  the 
cervical  epithelium.  The  nuclei  are  oval  and  vesicular,  and  in  many 
places  it  is  possible  to  make  out  cilia.  The  gland  cavities  are  empty 
or  contain  a  granular  material  that  takes  the  hsematoxylin  stain. 
The  glands  tally  in  every  particular  with  the  cervical  glands.  This 
nodule  is  undoubtedly  a  cervical  myoma  and  appears  to  be  the  only 
one  of  its  character  on  record.  It  has  evidently  started  near  the 
internal  os.  Otherwise  we  would  not  have  had  so  much  muscular 
tissue. 

Gyn.  No.  3898.    Path.  No.  934. 

Submucous  and  interstitial  myomata  and 
an  adenomyoma  situated  near  the  broad  lig- 
ament attachment  of  the  cervix  (Figs.  48  and  49) . 
General  pelvic  peritonitis,  left  side  hydro- 
salpinx simplex;  small  papillocystoma  of 
the    ovary. 

M.  J.,  married,  aged  thirty-eight,  white.  Admitted  October  22, 
1895.  This  patient  has  never  been  pregnant.  The  menses  began 
at  thirteen  and  were  regular  until  four  years  ago.  Since  then  they 
have  occurred  at  intervals  of  from  two  to  ten  weeks.  At  these  times 
the  flow  is  often  profuse,  at  other  times  scanty. 

Four  years  ago  a  tubo-ovarian  cyst  was  removed  by  Dr.  Senn. 


(   l.l;\  l<    \l.    AliKMl.MVDMATA  1  <i , 

Two  years  ago  she  had  several  hemorrhages,  and  during  the  next 
year  was  curetted  four  times.  For  ten  years  she  has  fell  a  stabbing- 
like  pain  al  intervals  in  the  left  ovarian  region.  Two  years  ago  she 
noticed  a  swelling  in  the  left  side  and  the  enlargement  reached  half- 
way to  the  umbilicus.  This  appeared  suddenly,  and  gradually 
disappeared  in  the  course  of  six  weeks.  Since  January,  L895,  she 
has  had  a  burning  pain  in  the  righl  ovarian  region. 

Operation,  October  23,  1895.  Hystero-salpingo-oophor- 
ectomy.  Removal  of  hsematoma  in  the  right  broad  ligament  and 
a  left  hydrosalpinx.  Adhesions  were  found  binding  down  the  tube 
and  ovary  and  there  was  encysted  peritonitis.  The  myomatous 
uterus  choked  the  pelvis.  The  omentum,  rectum  and  small  in- 
testine were  densely  adherent.  During  removal  of  the  uterus  the 
external  coats  of  the  ileum  were  ruptured  in  one  place,  requiring 
three  sutures. 

After  the  operation  the  temperature  gradually  rose,  reaching 
103.2°  F.  on  the  clay  of  her  death. 

On  the  second  day  after  the  operation  the  patient  complained 
of  excruciating  pain  in  the  right  side  over  the  site  of  the  intestinal 
suture.  This  became  more  and  more  intense  and  abdominal  dis- 
tention developed.  The  abdomen  was  opened  without  anaesthesia 
and  a  perforation  of  the  intestine  found  at  the  site  of  the  intestinal 
suture.     The  patient  died  that  same  evening. 

G  y  n  .  -  P  a  t  h  .  X  o  .  9  3  4.  The  specimen  consists  of  the 
uterus,  the  left  tube  and  ovary,  portions  of  the  wall  of  a  hsema- 
tonia  from  the  right  side,  also  of  a  small  piece  of  the  abdominal  wall. 

The  uterus  measures  7.5  by  5  by  7  cm.  and  is  covered  with  vas- 
cular adhesions.  Projecting  from  the  anterior  surface  is  a  sessile 
nodule,  5.5  by  5  by  4  cm.  This  for  the  most  part  is  smooth  and 
glistening,  but  shows  a  tew  delicate  vascular  adhesions  on  its  under 
surface.  On  its  right  side  it  presents  a  slightly  convoluted  appear- 
ance and  over  an  area  1.5  cm.  is  covered  with  a  yellowish  tissue  re- 
sembling mucous  membrane.  The  uterine  cavity  is  4.5  cm.  in  length 
and  3  cm.  in  breadth  at  the  fundus  (Fig.  Is  .  Its  mucosa  presents  a 
finely  granular  surface,  'nut  is  smooth  and  glistening  and  the  upper 


168 


ADENOMYOMA    OF    THE    UTERUS 


portion  shows  considerable  ecchymosis.  Projecting  into  the  cavity 
at  the  left  cornu  is  a  fold  of  mucous  membrane,  5  by  2  mm.  The 
uterine  walls  are  occupied  by  numerous  firm  white  nodules  varying 
from  .5  to  4.5  cm.  in  diameter.  All  of  the  nodules  present  the  typical 
myomatous  appearance. 

Right  side :    The  tissue  removed  consists  of  portions  of  the  wall 


Fig.  48. — Interstitial  uterine  myomata  with  a  small  diffuse  adenomyoma  in  the  cervix. 

(Natural  size.) 
Gyn.-Path.  No.  934.  The  uterus  has  been  amputated  through  the  cervix  and 
opened  anteriorly.  Situated  in  the  anterior  wall  is  a  myoma.  This  has  not  been  cut  through  the 
centre  and  consequently  one  portion  is  larger  than  the  other.  Near  the  uterine  cavity  is  a  myoma, 
about  1  cm.  in  diameter.  This  has  been  cut  in  two.  The  uterine  walls,  were  it  not  for  the  myo- 
mata, would  be  of  normal  thickness.  The  uterine  cavity  is  of  the  normal  length  and  its  mucosa 
unaltered.  On  the  right  side  of  the  cervix  at  a  point  approximately  corresponding  to  a  was  a  small 
diffuse  adenomyomatous  thickening,  part  of  which  is  represented  in  Fig.  49. 


of  a  hsematoma.     (The  appendages  had  been  removed  at  a  previous 
operation.) 

Left  side:  The  tube  at  a  point  1.5  cm.  from  the  uterus  is  4  mm. 
in  diameter,  but  gradually  dilates,  and  after  passing  outward  for 
6.5  cm.  forms  with  the  ovary  a  tubo-ovarian  mass,  measuring  6  by 
5  by  2.5  cm.  The  tube  is  covered  with  dense  adhesions,  has  thin 
transparent  walls,  through  which  the  folds  of  the  mucosa  can  be 
seen,  and  contains  a  clear  transparent  fluid.     The  tubo-ovarian  mass 


CERVICAL    ADENOMYOMATA  L69 

has  been,  for  the  most  part,  converted  into  a  thin-walled  cysl  con- 
taining dear  transparenl  fluid.  The  ovary  also  contains  a  firm. 
oval,  movable  body,  L.3  by  8  cm.  This,  on  section,  is  seen  to  be 
made  up  of  numerous  small  cysts,  in  the  walls  of  which  calcareous 

material  has  been  deposited. 

II  istological  E  x  a  m  i  n  a  t  io  n  . — The  cervical  glands 
present  the  usual  appearance.  The  uterine  mucosa  is  normal  in 
thickness;    its  surface  epithelium  is  intact  and  its  ulands  arc  abun- 


c , 


\2ft 


Fig.  49. — Adenomyoma  in  the  outer  portion  of  the  cervix  near  the   broad   ligami  m 

attachment.      (4  diameters.) 

Gyn.-Path.  No.  934.  The  section  is  through  the  right  side  of  the  cervix  in  Fig. 
48  at  a  point  approximately  indicated  by  a.  a  is  the  normal  cervical  mucosa.  The  surface 
epithelium  is  intact  and  the  characteristic  racemose  glands  are  seen.  Beneath  them  is  the  norma] 
stroma.  At  h  is  an  island  of  mucosa  situated  in  myomatous  muscle.  The  glands  in  this  island 
resemble  uterine  glands.  Some  of  them  are  dilated.  At  c  and  c  they  spread  out  in  "goose 
march"  fashion — that  is,  in  single  file.  All  of  these  glands  are  surrounded  by  the  characteristic 
stroma.     At  d  are  seen  isolated  glands  lying  in  direct  contact  with  the  muscle. 

dant  and  slightly  convoluted.  A  few  are  dilated,  bul  all  have  an  in- 
tact epithelium  and  many  of  them  contain  hyaline  material.  Here 
and  there  a  gland  extends  a  short  distance  into  the  muscle,  being  ac- 
companied by  stroma.  The  stroma  of  the  mucosa  in  its  superficial 
portion  shows  slight  hemorrhage. 

All  of  the  nodules  scattered  throughout  the  uterus  present  the 
typical  myomatous  appearance  and  the  large  nodule  in  the  anterior 
wall  shows  considerable  hyaline  degeneration.  The  whitish-yellow 
area  attached  to  the  riidit  side  of  the  uterus,  and  resembling;  mucous 


170  ADENOMYOMA    OF    THE    UTERUS 

membrane,  is  covered  with  one  layer  of  cylindrical  epithelium,  on 
which  it  is  in  places  possible  to  detect  cilia.  Beneath  the  epithelium 
is  a  varying  amount  of  stroma  similar  to  that  of  the  uterine  mucosa. 
This  stroma  shows  considerable  small  round-cell  infiltration  and 
has  here  and  there  throughout  it  oval  or  round  glands  lined  with 
C3dindrical  epithelium.  The  tissue  external  to  this  stroma  is  com- 
posed of  non-striped  muscle  fibres  and  connective  tissue.  Scat- 
tered throughout  this  muscular  tissue  are 
glands,  in  some  places  as  many  as  eight  being 
seen  on  cross-section  (Fig.  49) .  Some  are  oval  or  round, 
others  are  dilated.  All  have  an  intact  epithelial  lining  and  in  many 
places  it  is  possible  to  make  out  cilia.  These  glands  are  surrounded 
by  the  typical  stroma.  Scattered  here  and  there  throughout  the 
thickened  wall  are  numerous  glands,  some  lying  in  the  myomatous 
muscle  immediately  beneath  the  peritoneum,  others  in  what  appears 
to  be  normal  muscle.  Some  of  the  glands  contain  blood  and  one  has 
become  cystic.  The  growth  is  an  intraligamentary  adenomyoma, 
but  its  exact  relations  cannot  be  determined,  as  the  tissue  was  much 
mutilated  during  operation. 

Left  side:  The  tube  is  covered  with  dense  adhesions,  but  its 
mucous  membrane  is  normal.  The  cyst  of  the  ovary  is  apparently 
lined  with  a  single  layer  of  epithelium ;  it  has  several  papillary  masses 
springing  from  its  inner  surface. 

Diagnosis  . — Submucous  and  interstitial  myomata.  Cer- 
vical adenomyoma.  Normal  uterine  mucosa.  General  pelvic  peri- 
tonitis. 

Left  side :  Hydrosalpinx  simplex.  Small  papillocj^stoma  of  the 
ovary. 


CHAPTER   VIIJ 

CONDITION  OF  THE  TUBES  AND  OVARIES  WHEN   ADENOMYOMA    OF 

THE  UTERUS  EXISTS 

In  forty-five  cases  we  have  carefully  examined  the  tubes  and 
ovaries  to  see  if  there  might  be  any  causal  relation  between  them  and 
the  development  of  adenomyoma  in  the  uterus.  We  have  failed  to 
find  proofs  of  any  such  relation.  In  fifteen  cases  we  found  the  ap- 
pendages on  both  sides  normal.  In  the  remaining  thirty  cases  the 
appendages  on  one  or  both  sides  were  covered  with  adhesions,  there 
being  a  mild  degree  of  pelvic  peritonitis,  in  part  probably  due  to  the 
discrete  myomatous  growth,  but  to  a  greater  extent  undoubtedly 
caused  by  the  diffuse  myoma.  In  Case  2806  there  was  a  right 
tubo-ovarian  abscess  and  a  partially  healed  salpingitis  on  the  left 
side.  The  left  ovary  in  Case  3136  contained  a  small  cyst;  in  Case 
389S  the  left  tube  was  the  seat  of  a  hydrosalpinx,  the  left  ovary 
of  a  small  papillocystoma.  There  was  a  very  large  multilocular 
cystadenoma  of  the  left  ovary  in  Case  4364. 

In  a  few  cases  there  was  a  healed  salpingitis.  In  Gyn.  No.  2706 
and  in  Path.  Xo.  8393  a  hydrosalpinx  was  present.  In  Gyn.  No. 
12,080  an  acute  salpingitis  was  found,  and  in  Gyn.  No.  2806 
a  tubo-ovarian  abscess. 

Where  pelvic  adhesions  are  present  the  normal  maturing  of  the 
follicle  is  often  interfered  with,  and  we  consequently  find  small  Graafian 
follicle  or  corpus-luteum  cysts.  In  Gyn.  No.  2706  we  found  an  ova- 
rian cyst  measuring  13  by  12  by  11  cm.;  in  Gyn.  No.  3898  a  very 
small  papillocystoma  of  the  ovary.  In  Gyn.  9457  one  ovary  con- 
tained a  large  cyst  with  changes  very  suggestive  of  an  early  car- 
cinoma. These  pathological  changes  in  the  ovaries  are  not  in  ex- 
cess of  those  usually  found  in  a  corresponding  number  of  abnormal 
adnexa  examined  in  the  laboratory.     Adenomyoma  of  the  uterus 

171 


172  ADEXOMYOMA    OF    THE    UTERUS 

does  not  seem  to  materially  increase  the  incidence  of  pathological 
changes  in  the  tubes  or  ovaries. 

In  forty-nine  cases  in  which  we  examined  the  uterus  for  adhe- 
sions, in  twenty -five  the  organ  was  perfectly  smooth  and  in  twenty- 
four  was  more  or  less  adherent.  The  adhesions,  as  a  rule,  were  con- 
fined to  the  posterior  surface  of  the  organ;  only  rarely  was  the  an- 
terior surface  implicated. 


CHAPTER  IX 

THE  CLINICAL  PICTURE  IN  CASES  OF  ADENOMYOMA  OF  THE  UTERUS 

This  will,  of  course,  vary  with  the  situation  of  the  growth  and  also 
with  the  size  and  situation  of  the  discrete  myomata  so  often  asso- 
ciated with  adenomyoma. 

Where  the  diffuse  growth  is  the  chief  factor,  the  patient  usually 
gives  a  history  of  lengthened  menstrual  periods,  accompanied  by  a 
meat  deal  of  pain,  sometimes  limited  to  the  uterus,  but  often  also 
referable  to  the  back  and  extending  to  the  legs.  This  pain  may  be 
dull,  aching,  or  grinding  in  character.  As  the  disease  progresses 
the  menorrhagia  may  be  replaced  by  a  continuous  hemorrhagic  dis- 
charge, as  was  observed  in  Cases  2573  and  6083 ;  or  alarming  bleeding- 
may  occur,  as  in  Case  7153.  This  h  e  m  o  r  r  h  a  g  e  is  readily 
accounted  for  when  we  take  into  consideration  the  greatly  increased 
amount  of  uterine  mucosa  existing  under  such  circumstances,  com- 
prising that  lining  the  uterine  cavity  and  also  that  liberally  dis- 
tributed throughout  the  diffuse  myomatous  growth.  The  pain 
is  also  easily  explained  when  we  remember  that  the  myomatous 
tissue  is  treated  as  a  foreign  body.  In  cases  of  discrete  myomata 
there  is  also  pain,  but  the  uterus  readily  forces  the  nodule  toward 
the  peritoneal  or  submucous  surface.  In  the  diffuse  growth,  while 
this  is  also  possible,  the  difficulties  in  its  accomplishment  arc  much 
greater,  as  the  mass  is  so  intimately  interwoven  with  the  normal 
muscle.  At  each  menstrual  period  the  uterine  mucosa  is  congested 
and  thickened.  In  adenomyoma  with  an  increased  amount  of  Mood 
in  the  islands  of  the  mucosa  scattered  through  the  diffuse  growth  we 
should  naturally  have  increased  tension,  producing  a  tenderness  or 
sharp  pain,  referred  to  the  uterus,  during  the  period. 

Discharge.  In  analyzing  the  clinical  histories  of  thirty-seven 
cases  for  vaginal  discharge  we  find  that  twenty-six  were  free 
from  any  flow  between  menstrual  periods  or  between  hemorrhag  - 


174  ADENOMYOMA    OF    THE    UTERUS 

In  eleven  there  was  a  distinct  flow,  chiefly  leucorrhceal  in  character 
and  usually  non-irritating.  In  a  few  instances  it  was  greenish  or 
yellowish  in  color  and  offensive.  In  case  No.  3192  there  was  a  fre- 
quent white  discharge  and  in  Sanitarium  No.  1944  a  watery  dis- 
charge was  present.  This  might  readily  be  accounted  for,  as  the 
patient  had  a  haemoglobin  of  only  40  per  cent.  We  are  naturally 
surprised  to  see  that  so  few  of  the  patients  gave  a  distinct  history  of 
vaginal  discharge.  When  we  remember,  however,  that  the  uterine 
mucosa  and  that  situated  deep  down  in  the  muscle  are  practically 
normal,  this  relative  absence  of  the  vaginal  discharge  is  readily  ex- 
plained. In  those  cases  in  which  the  adenomyoma  becomes  sub- 
peritoneal or  intraligamentary  and  forms  large  cysts,  pressure  symp- 
toms may  occur,  and  such  cysts  are  usually  firmly  fixed  in  the  pelvis. 
This  is  especially  true  of  the  intraligamentary  variety,  where  the 
tumor  is  prevented  from  rising  into  the  abdomen  by  the  broad  liga- 
ment. 

Age. — We  have  found  this  disease  in  women  as  young 
as  nineteen  and  as  old  as  sixty.  In  sixty-six  patients  in  whose  cases 
the  age  was  obtained  the  following  incidence  was  noted : 

At  nineteen 1  case 

Between  twenty  and  thirty 3  cases 

Between  thirty  and  forty 21      " 

Between  forty  and  fifty 19     " 

Between  fifty  and  sixty 21     " 

At  sixty 1  case 

This  table  goes  to  show  that  the  period  between  the  fourth  and  sixth 
decades  presents  the  highest  incidence  of  this  disease.  The  pro- 
cess seems  to  be  a  slow  one,  as  is  evidenced  by  the  clinical  histon^. 
Some  patients  dated  their  trouble  back  five  or  ten  years,  while  others 
had  been  complaining  for  only  a  few  months.  We  have  found  this 
disease  equally  prevalent  in  the  colored  and  white  races. 

Relation  to  Pregnancy. — We  have  examined  the  clinical  histories 
in  forty-nine  of  the  cases  of  diffuse  adenomyoma  of  the  uterus  to 
determine  the  relative  frequency  of  pregnancy,  with  the  following- 
results  :  nine  patients  were  single,  six  were  sterile,  two  had  had  mis- 
carriages, thirty-two  had  had  children. 


CLINICAL    PICTURE    l\    ADENOMYOMA    OF    OTERUS  L75 

One  of  the  sterile  patients  had  not  married  until  over  fort)'  years 
of  age,  and  accordingly  mighl  be  equally  well  classed  with  the  single 
patients  from  i  hal  standpoinl . 

In  thirty-one  of  the  thirty-four  patients  thai  had  had  either 
children  or  miscarriages  we  have  accurate  records  of  the  number  of 
children.  In  all,  one  hundred  and  forty-one  children  were  born, 
approximately  four  children  to  each  woman.  In  a  few  instanc 
woman  had  had  only  one  child,  while  in  one  case  the  patient  was  the 
mother  of  thirteen,  in  another  of  eleven,  in  a  third  caseof  ten.  These 
figures  show  thai  the  disease  is  found  in  single  as  well  as  in  married 
women,  and  furthermore  that  it  does  not  seem  in  any  way  to  militate 
against  normal  pregnancy. 

Physical  Examination. — On  making  a  vaginal  examination, 
when  the  growth  is  confined  to  the  uterus  we  find  the  cervix 
practically  normal,  the  body  of  the  uterus  considerably  enlarged 
and  very  hard.  In  the  majority  of  the  cases  we  also  feel  definite 
small  round  bosses  due  to  discrete  myomata.  In  the  early  cases  the 
organ  may  be  free,  but  very  often  it  is  enveloped  in  adhesions  and 
firmly  fixed.  In  some  cases  (Fig.  13)  the  organ  will  be  symmetrical, 
very  firm,  and  the  size  of  that  of  a  two  or  three  months'  pregnancy. 
Where  the  growth  is  large  and  cystic  and  lies  in  the  abdominal 
cavity,  it  is  impossible  to  differentiate  it  from  an  ordinary  myoma- 
tous uterus  pure  and  simple  or  associated  with  an  ovarian  cyst. 
If  the  growth  be  intraligamentary,  it  is  more  firmly  fixed  in  the 
pelvis,  and  is  then  comparable  to  a  broad  ligament  myoma  of  to  an 
intraligamentary  cyst,  although  it  may  simulate  a  large  pelvic  ab- 
scess.    The  clinical  history  of  pus  will,  however,  be  wanting. 

From  the  preceding  it  will  be  seen  that  if  we  have  a  patient  giv- 
ing a  history  of  an  ever-increasing  menstrual  How.  and  showing  on 
pelvic  examination  a  moderately  enlarged  and  firm  and  possibly 
nodular  uterus,  which  on  curettage  yields  a  rather  thick  bul  normal 
mucosa,  we  may  reasonably  suspect  an  adenomyoma.  Of  course, 
however,  the  hemorrhages  may  occasionally  be  duo  entirely  to  the 
presence  of  discrete  submucous  myomata. 

Where  carcinoma  of  the  body  of  the  uterus  is  present  the  organ 


176 


ADENOMYOMA    OF   THE    UTERUS 


is  likely  to  be  soft.  Rarely  small  and  isolated  myomata  are  found 
on  its  surface,  and  curettage  yields  adenocarcinoma  instead  of 
normal  mucosa. 

Where  an  adenomyoma  is  subperitoneal  or  intraligamentary  the 
diagnosis  is  impossible  until  the  abdomen  is  opened.  But  then, 
given  a  myomatous  uterus  containing  large  cystic  areas  with  smooth 
velvety  linings  and  chocolate-colored  contents,   adenomyoma  will 


Ut.  cavity 


Fig.  50. — A  cystic  myoma  macroscopically  simulating  a  cystic  adenomyoma.     (f  natural 

size.) 

Path.  No.  10,771.  The  picture  represents  a  cross-section  through  the  tumor  as  seen 
in  the  upper  left  corner,  the  section  being  made  from  a  to  a'.  A  small  portion  of  the  uterine 
cavity  is  seen.  On  one  side  of  it  are  cross-sections  of  two  simple  myomata.  At  b  we  have  a  cystic 
myoma  with  a  slightly  irregular  cavity  that  was  filled  with  chocolate-colored  blood.  We  felt  con- 
fident that  a  histological  examination  would  reveal  a  cystic  adenomyoma.  The  walls  of  the  cavity 
were,  however,  composed  of  myomatous  tissue  that  had  undergone  partial  hyaline  degeneration 
and  the  cavity  was  totally  devoid  of  any  epithelial  lining.  There  had  evidently  been  simple 
cystic  formation  as  a  result  of  the  breaking  down  of  hyaline  tissue.  Hemorrhage  had  taken  place 
later.  This  is  the  only  one  of  our  cases  in  which  a  tumor  presented  such  a  gross  appearance 
and  did  not  yield  adenomyoma  on  histological  examination. 


usually  be  found.  Fig.  50  represents  the  only  exception  that  we 
have  noted.  Here  the  uterus  contained  several  myomata.  One  of 
them  had  a  central  cavity  which  was  filled  with  chocolate-colored 
contents.  This  myoma  had  undergone  a  good  deal  of  hyaline  de- 
generation. In  the  centre  was  a  cystic  area  and  into  this  hemorrhage 
had  taken  place.     It  was  not  an  adenomyoma. 


(TIAPTKR   X 

DIFFERENTIAL  DIAGNOSIS  IN  CASES  OF  ADENOMYOMA  OF  THE 

UTERUS 

Diffuse  adenomyoina  of  the  uterus  has,  thanks  to  the  work  of 
vod  Recklinghausen,  become  a  definite  pathological  entity,  bill  here- 
tofore it  has  not  impressed  surgeons  as  having  a  very  definite  and 
peculiar  train  of  symptoms. 

In  the  early  years  of  our  investigations  we  also  failed  to  detect 
it  clinically,  but  in  the  early  and  fairly  advanced  stages  of  the  process 
so  definite  are  the  symptoms  that  the  hospital  assistant  now  fre- 
quently comes  and  says  that  a  given  case  has  all  the  signs  of  an 
adenomyoma  and  that  he  feels  sure  that  this  is  the  cause  of  the 
bleeding.  His  diagnosis  can,  of  course,  be  greatly  strengthened  by 
the  histological  appearances  of  the  uterine  mucosa,  and  then  the 
gross  appearance  of  the  uterine  wall  on  section  often  suffices  to 
clinch  the  diagnosis  after  the  uterus  has  been  removed,  even  before 
a  histological  examination  has  been  made.  We  accordingly  see  that 
this  disease  has  very  characteristic  symptoms  and  must  be  given  its 
proper  place  in  our  list  of  uterine  diseases  which  may  be  clinically 
recognized. 

Clinically  adenomyoma  has  to  be  differentiated  from  any  pelvic 
condition  that  may  cause  uterine  hemorrhage.  The  following  are 
those  diseases  that  are  likely  to  produce  or  be  associated  with  uterine 
bleeding. 

1.  Uterine  polypi. 

2.  Large  venous  sinuses  in  the  mucosa. 

3.  Marked  proliferation  of  the  stroma  of  the  mucosa. 

4.  Very  large  and  dilated  uterine  glands  with  overgrowth  of  the 
stroma  of  the  mucosa. 

5.  Uterine  myomata. 

6.  Sarcoma. 

12  177 


178 


ADENOMYOMA    OF   THE    UTERUS 


7.  Abortion. 

8.  Chorio-epithelioma. 

9.  Tubal  pregnancy. 

10.  Salpingitis  and  endometritis. 

11.  Carcinoma  of  the  uterus. 


-H.B. 


Fig.    51. 


(4 


UTERINE  POLYPI 

These  may  be  situated  in  the  cervix  or  body,  and  are  usually 
associated  with  a  slight  irritating  uterine  discharge  and  often  with 

bleeding.  This  bleeding  may 
manifest  itself  as  an  exacerba- 
tion of  the  usual  flow  at  the 
period  or  there  may  be  a  slight 
discharge  of  blood  between 
periods. 

If  the  growth  projects  through 
the  cervix,  the  recognition  of  the 
polyp  is  easy  and  its  removal  is 
followed  by  a  total  cessation  of 
the  symptoms.  Should  the  polyp 
be  in  the  cavity  of  the  uterus,  it 
may  be  brought  away  with  the 
curette,  and  then  all  symptoms 
cease. 

Polypi,  whether  situated  in 
the  cervix  or  in  the  body,  are 
nothing  more  than  portions  of 
normal  mucosa  which  have  for 
some  reason  been  partially  or 
completely  extruded  (Fig.  51). 

On    histological    examination 
they  are  recognized  by  their  oval 
or  oblong  shape  and  by  the  fact  that  they  are  covered  on  three  sides 
by  epithelium. 

In  cases  of  diffuse  adenomyoma  curettage  gives  only  temporary 


SMALL      UTERINE      POLT 

diameters.) 

Gyn.-Path.  No.  659.  This 
section  is  from  the  fundus  of  the  uterus. 
The  mucosa  lining  the  uterine  cavity  is  rather 
thin,'  and  has  a  smooth  surface  covered  with 
one  layer  of  epithelium.  Scattered  through- 
out the  mucosa  are  a  small  number  of  nor- 
mal uterine  glands.  Projecting  from  it  is  a 
tongue-shaped  polyp  (a),  which  points  down- 
ward. Its  surface  is  covered  with  one  layer 
of  epithelium,  continuous  with  that  covering 
the  surface  of  the  mucosa.  Its  substance 
contains  glands  differing  from  those  in  the 
mucosa  only  in  that  a  few  of  them  are  dilated. 
The  stroma  of  the  polyp  merges  impercep- 
tibly into  that  of  the  normal  mucosa  and  is  of 
the  same  character.  It  is  evident  that  this 
is  in  reality  the  result  of  a  partial  extrusion 
of  the  normal  mucosa. 


DIFFERENTIAL    DIAGNOSIS 


L79 


relief,  and  on  histological  examination  nothing  bul  perfectly  normal 
mucosa  can  be  detected  in  the  scrapings. 


LARGE  VENOUS  SINUSES  IN  THE  UTERINE  MUCOSA  CAUSING  FREE 

HEMORRHAGES 

In  "  Cancer  of  the  Uterus"  I  reported  a  case  in  which,  on  account 
of  the  frequent  uterine  hemorrhages,  carcinoma  was  suspected  and 
hysterectomy  contemplated.     Examination  of  the  scrapings  showed 


~40^r%%---'--\  :■■■■■;■':■,.'  '     '7^5- 


m  ■  i 


mm 


p#«    mmm-  mm 

.~n      <  fV-.^.:.-."  -V.:   ^        >:-•     :./  i" 

.    r^:   >:--:'.-  -:*?.*--:     '■■■    ,).■  ■  .  .    -> 


..  b 


^ 


Jf.J3ecJ<ox- 


Fig.  •">— — Large  venous  sinuses  in  the  uterine  mucosa  causing  severe  bemorrb 

80  diameters.  I 

Gyn.-Path.  No.  2048.  a  is  a  portion  of  the  surface  epithelium,  which  is 
greatly  flattened.  In  the  lower  pari .  as  well  as  in  the  upper  third  of  the  field,  are  several  uterine 
glands  of  the  usual  size  and  shape,  and  lined  with  one  layer  of  cylindrical  epithelium.     They 

arc    perfectly  normal,  and  arc  surrounded  by  the  normal  stroma  of  the  mucosa.      Over  one   half 

of  the  section  is  made  up  of  three  large  venous  sinuses  b  .  showing  exceedingly  delicate  walls. 
That  there  is  do  malignant  process  is  clear.  It  is  little  to  be  wondered  at  that  free  hemorrhages 
should  have  taken  place,  when  such  large  blood  sinuses  existed. 

that  the  bleeding  was  due  to  enormous  sinuses  scattered  throughout 
the  uterine  mucosa.  The  patienl  was  greatly  benefited  by  the  curet- 
tage. A  year  later  she  was  again  curetted,  and  in  a  short  time  she 
felt  better  than  she  had  for  years. 


180  ADENOMYOMA    OF    THE    UTERUS 

The  difference  between  the  mucosa  in  this  case  and  that  in  a  case 
of  adenomyoma  is  very  plain,  as  can  be  gathered  from  Fig.  52. 

MARKED  PROLIFERATION  OF  THE  STROMA  OF  THE   MUCOSA  ASSOCIATED 
WITH  COPIOUS  UTERINE  HEMORRHAGES 

On  page  478  of  "  Cancer  of  the  Uterus ' '  I  described  several  cases 
in  which  free  uterine  hemorrhage  wTas  apparently  due  to  a  marked 
proliferation  of  the  stroma  of  the  uterine  mucosa,  the  glands  re- 
maining perfectly  normal.  The  stroma  was  very  rich  in  cellular 
elements;  the  nuclei  were  slightly  larger  than  normal.  Numerous 
nuclear  figures  could  be  seen  scattered  throughout  the  stroma,  and 
were  it  not  for  the  fact  that  the  spaces  between  the  glands  were  every- 
where approximately  equal,  one  might  have  suspected  sarcoma. 

The  histological  picture  shows  clearly  the  difference  in  the  mucosa 
of  cases  of  this  character  and  those  of  diffuse  adenomyoma.  Clinic- 
ally, the  contrast  is  even  more  striking.  All  the  patients  were  under 
twenty-five  years  of  age  and  in  each  case  the  hemorrhages  ceased  in 
the  course  of  a  few  years. 


A  THICK  UTERINE  MUCOSA;    VERY  LARGE  AND  DILATED  UTERINE  GLANDS 
WITH  AN  OVERGROWTH  OF  THE  STROMA  OF  THE  MUCOSA 

Clinically  we  have  a  by  no  means  small  group  of  cases  in  which 
a  patient,  usually  between  forty  and  fifty,  comes  complaining  of 
a  very  profuse  menstruation  and  at  times  of  an  intermenstrual  flow 
or  a  leucorrhoeal  discharge,  and  in  which  carcinoma  of  the  body  of 
the  uterus  is  suspected. 

On  histological  examination  we  find  a  most  characteristic  picture 
(Fig.  53).  The  mucosa  is  much  thickened.  The  glands  are  large 
and  many  of  them  are  dilated.  This  dilatation  is,  however,  not  due 
to  occlusion  and  cj^st  formation,  as  the  gland  epithelium  is  proliferated 
and  higher  than  usual  instead  of  flattened.  Many  of  the  enlarged 
glands- are  irregular  in  outline. . 

The  stroma  of  the  mucosa  is  very  rich  in  cell  elements  and  nu- 
clear figures  can  at  times  be  detected. 

I  have  examined  the  mucosa  in  many  such  cases  and  am  at  a 


IMFFKHKVn  Al.    DIAGNOSIS 

b 


IM 


Fig.  53.    -Thickening of  the  uterine  mucosa.   Marked  dilatation  of  some  of  ihk  glands 
without  ant;  atrophy  of  their  epithelium;  veri  densestroma.     (38  diameters. 

Gyn.-Path.  No.  7026.  The  section  is  a  portion  of  a  scraping.  The  surface  epithe- 
lium is  intact  as  seenasaand  o.  At  b  are  two  normal  uterine  -lands.  Fully  half  of  the  clan. Is 
are  more  or  less  dilated.     At  c  is  an  irregular  and  dilated  gland  filled  with  coagulated  serum. 

d  and  e  are  also  dilated  bul  nol  spherical  -lands.  The  gland  /  is  markedly  dilated  and  spherical. 
In  none  of  the  dilated  -lands  is  there  any  atrophy  of  the  epithelium.  The  stroma  between  the 
-lands  is  very  dense,  in  some  of  these  cases  large  veins  are  found  scattered  throughout  the 
stroma.  Given  such  a  mucosa  as  this,  one  can  say  with  almost  absolute  certainty  that  the 
patient  lias  had  very  profuse  menstrual  bleeding. 


182  ADENOMYOMA   OF   THE    UTERUS 

loss  to  give  the  condition  a  definite  name.  With  such  a  mucosa  one 
can  say  with  absolute  certainty  that  the  patient  has  been  subject 
to  very  free  uterine  bleeding.     It  is  not  malignant. 

The  clinical  picture  in  this  condition  resembles  to  some  extent 
that  of  diffuse  adenomyoma  of  the  uterus,  but,  as  noted,  the  histo- 
logical patterns  are  totally  different. 

UTERINE  MYOMATA 

Myomata  are  primarily  interstitial  and  may  become  subperitoneal 
or  submucous.  Often  these  give  rise  to  no  symptoms  whatever 
save  those  of  pressure.  When  the  myomata  become  submucous, 
more  or  less  menorrhagia  is  present.  This  is  due  to  the  fact  that  the 
uterine  mucosa  is  put  on  tension  by  the  myoma,  which  is  gradually 
forcing  its  way  into  the  cavity  of  the  uterus.  I  have  known  a  small 
submucous  myoma  give  rise  to  almost  fatal  hemorrhage,  while,  on 
the  other  hand,  a  patient  with  an  89-pound  myoma  had  never  had 
any  excessive  menstruation.  The  hemorrhage  depends  entirely 
on  the  situation  of  the  tumor. 

Bimanual  examination  will  often  reveal  the  presence  of  a  large 
myomatous  uterus. 

On  curettage  normal  or  atrophic  uterine  mucosa  will  be  found, 
provided  the  tubes  and  ovaries  are  normal. 

The  differential  diagnosis  between  a  uterus  containing  simple 
discrete  myomata  and  one  the  seat  of  a  diffuse  adenomyoma  is  often 
difficult,  if  one  of  the  simple  myomata  be  submucous.  The  difficulty 
is  increased  by  the  fact  that  there  is  a  marked  tendency  for  discrete 
myomata  to  be  associated  with  a  diffuse  adenomyoma.  How- 
ever, where  simple  myomata  exist  there  may  not  be  the  marked 
tenderness  at  the  menstrual  period,  so  frequently  noticed  in  adeno- 
myoma, and  further,  examination  of  the  curettings  will  usually 
demonstrate  a  much  thicker  mucosa  in  the  adenomyomatous 
uterus. 


MITKKKNTIAI.     DIAGNOSIS  L83 

SARCOMA  OF  THE  UTERUS 

In  the  examination  of  over  twelve  hundred  myomata  we  have 
found  sarcoma  developing  in  or  associated  with  uterine  myomata 
in  seventeen  cases. 

The  points  of  difference  between  cases  of  uterine  myomata  and 
diffuse  adenomyoma  apply  equally  well  to  those  of  sarcoma  of  the 
uterus.  In  sarcoma,  however,  we  have  a  history  of  a  tumor  which 
has  probably  lain  dormant  for  years,  and  then  suddenly  has  com- 
menced to  grow  rapidly.  If  portions  of  the  growth  project  into  the 
uterine  cavity,  the  diagnosis  of  sarcoma  can  readily  be  made  from 
pieces  removed  with  the  curette. 

Where  sarcoma  arises  primarily  from  the  uterus  and  not  from  a 
pre-existing  myoma,  the  growth  may  also  be  correctly  diagnosed 
from  scrapings,  if  portions  of  it  project  into  the  uterine  cavity. 

ABORTION 

Uterine  bleeding  often  follows  a  miscarriage,  especially  when 
remnants  of  the  placenta  have  been  left  behind.  This  bleeding  is 
usually  continuous,  while  in  adenomyoma  the  bleeding  usually  con- 
sists in  an  exacerbation  of  the  menstrual  period.  Further,  in  the  one 
case  there  is  likely  to  be  a  history  of  a  recent  conception;  in  the 
other  the  bleeding  has  been  noticed  for  months  or  years  and  has 
gradually  increased. 

Where  an  abortion  has  occurred  placental  villi  or  decidual  re- 
mains are  usually  obtained  on  curettage.  In  diffuse  adenomyoma  a 
perfectly  normal  uterine  mucosa  is  found. 

CHORIOEPITHELIOMA 

Chorioepithelioma  is  infinitely  rarer  than  adenomyoma,  and 
follows  an  intrauterine  or  extrauterine  pregnancy  usually  a  hy- 
datid mole. 

The  clinical  history  is  generally  sufficient.  Examination  of  the 
scrapings  will  aid  materially  in  settling  the  question.  Where  chorio- 
epithelioma exists  we  usually  have  placental  villi  showing  marked 


184  ADENOMYOMA    OF   THE    UTERUS 

proliferation  of  the  syncytium  and  usually  of  Langhans'  layer. 
There  are  also  many  vacuoles  between  and  also  in  the  masses  of 
cells  of  the  growth. 

While  one  cannot  from  the  scrapings  differentiate  absolutely 
between  a  very  active  hydatid  mole  and  chorioepithelioma,  yet  one 
can  say  with  certainty  that  a  pregnancy  has  existed  and  that  the 
growth,  if  not  actually  malignant,  is  very  suspicious.  In  the  cases 
of  diffuse  adenomyoma  the  mucosa  is  perfectly  normal. 

TUBAL  PREGNANCY 

Pregnancy  in  the  Fallopian  tube  is  usually  associated  with  a 
cessation  of  the  period  for  one  or  two  months,  followed  by  a  slight 
continuous  uterine  bleeding.  In  some  cases  the  periods  have  been 
perfectly  regular,  but  the  last  period  has  never  completely  stopped 
and  the  patient  has  continued  to  lose  a  little  blood.  Later  she  com- 
plains of  pain  in  one  side,  and  if  she  does  not  consult  a  physician 
she  suddenly  collapses  from  internal  hemorrhage.  Pelvic  examina- 
tion before  rupture  of  the  tube  will  show  slight  enlargement  of  the 
uterus  with  a  small  mass  on  one  or  the  other  side. 

In  adenomyoma  the  periods  remain  regular,  but  are  profuse, 
and  there  is  usually  no  intermenstrual  bleeding.  Moreover,  there  is 
little  or  no  intermenstrual  pain.  Examination  of  the  uterine 
mucosa  in  the  one  case  usually  yields  a  slight  decidual  formation ;  in 
the  adenomyoma,  a  normal  mucosa. 

SALPINGITIS  AND  ENDOMETRITIS 

The  patient  with  pelvic  inflammation  usually  gives  a  history  of 
an  acute  infection  followed  by  a  profuse  uterine  discharge  and  pain 
laterally.  Bleeding  is  occasionally  present  and  may  suggest  adeno- 
myoma. 

On  examination  of  the  scrapings  we  usually  find  a  thinning  out 
of  the  mucosa  and  definite  infiltration  with  small  round  cells  or  poly- 
morphonuclear leucocytes.  In  those  cases  in  which  tuberculosis  is 
present  typical  tubercular  areas   or  areas  of   caseation  are  seen. 


DIFFERENTIAL    DIAGNOSIS  Is"' 

Both  pictures  are  totally  different  from  that  presented  by  the  normal 
uterine  mucosa  associated  with  diffuse  adenomyoma  of  the  uterus. 


CARCINOMA  OF  THE  UTERUS 

Carcinoma  of  the  uterus  is  clinically  divisible  into  two  varietii  - 

1.  Carcinoma  of  the  cervix. 

2.  Carcinoma  of  the  body  of  the  uterus. 

Usually  the  first  symptom  of  a  carcinoma,  whether  situated  in 
the  cervix  or  body,  is  uterine  hemorrhage.  This  is  frequently  sudden 
and  may  be  meagre  or  abundant.  The  hemorrhages  are  usually 
intermenstrual.  In  adenomyoma  the  bleeding  is  usually  profuse  at 
the  periods  and  there  is  no  hemorrhage  between  the  periods.  In  car- 
cinoma a  watery  or  purulent  and  usually  offensive  discharge  is  pres- 
ent between  the  periods.  This  is  due  to  disintegration  of  the  de- 
generating carcinomatous  tissue.  In  adenomyoma  there  is  usually 
no  such  discharge  because  there  is  no  dissolution  of  tissue. 

Where  carcinoma  of  the  cervix  exists  the  growth  can  usually  be 
detected  on  digital  examination.  Sometimes  it  is  recognized  as  a 
cauliflower-like  outgrowth  from  the  cervical  lips,  but  in  the  later 
stages  a  crater-like  cavity  is  present  where  the  cervix  should  be, 
and  the  vaginal  vault  is  board-like  in  consistency  as  a  result  of  car- 
cinomatous infiltration.  In  cases  of  diffuse  adenomyoma  of  the 
uterus  the  cervix  is  usually  perfectly  normal. 

'Where  carcinoma  of  the  body  of  the  uterus  exists,  uterine  scrap- 
ings yield  the  characteristic  pattern  of  adenocarcinoma  and  the  cell 
changes  leave  no  doubt  as  to  the  malignant  nature  of  the  growth. 
In  cases  of  adenomyoma  the  mucosa  lining  the  uterine  cavity  is,  od 
the  contrary,  perfectly  normal. 


CHAPTER  XI 
TREATMENT  OF  ADENOMYOMATA  OF  THE  UTERUS 

Not  infrequently  the  case  will  be  looked  upon  as  one  of  simple 
myoma  and  its  true  character  will  be  determined  only  after  opera- 
tion. Should  a  diagnosis  be  made,  abdominal  hysterectomy  is  in- 
dicated provided  the  bleeding  is  so  severe  that  the  patient's  health  is 
being  undermined.  Myomectomy  is  inapplicable,  as  the  growth  is  so 
interwoven  with  the  normal  muscle  that  it  cannot  be  shelled  out. 
In  cases  of  intraligamentary  and  cystic  adenomyomata  evacuation  of 
the  cyst  contents  will  often  be  found  necessary,  before  it  is  possible 
to  shell  the  tumor  and  the  uterus  out  from  the  pelvic  floor.  As 
these  growths  will  lift  up  the  peritoneum  of  Douglas'  sac,  it  will  be 
advisable  to  dissect  the  peritoneum  back  so  that  it  can  be  replaced 
after  removal  of  the  tumor,  thus  avoiding  a  raw  area  on  the 
pelvic  floor.  If  this  precaution  be  not  taken,  intestinal  loops  are 
apt  to  drop  down  and  become  adherent. 

In  these  cases  supravaginal  hysterectomy  is  all  that  is  required. 
This  occasionally  greatly  diminishes  the  dangers  of  the  operation. 
For  example,  in  one  of  our  recent  cases  in  which  we  suspected  carci- 
noma of  the  body  a  complete  abdominal  hysterectomy  was  com- 
menced. Release  of  the  cervical  portion  proved  to  be  very  difficult 
on  account  of  the  very  long  cervix.  With  the  gradual  loosening  up 
of  the  uterus  we  found  strong  suggestions  of  adenomyoma.  The 
uterus  was  accordingly  amputated  through  the  cervix  and  at  once 
opened.  The  diagnosis  of  adenomyoma  was  immediately  confirmed. 
In  this  case  complete  removal  of  the  uterus  would  have  entailed 
much  painstaking  dissection  and  would  have  prolonged  the  operation 
in  the  case  of  a  very  anaemic  woman. 


1S6 


CHAPTER  XII 

PROGNOSIS  IN  CASES  OF  ADENOMYOMA  OF  THE  UTERUS 

When  considering  these  growths  in  189(5,  I  agreed  with  von 
Recklinghausen  that  they  are  benign.1  The  glands  are  perfectly 
normal  uterine  glands  and  are  surrounded  by  the  normal  stroma  of 
the  mucosa.  They  are  confined  entirely  to  the  new  growth  and 
do  not  show  the  slightest  tendency  to  invade  the  normal  muscle. 
Wherever  possible,  it  is  always  well  to  back  up  the  impressions  gained 
from  histological  study  by  the  clinical  sequence.  And  in  two  of 
our  cases  this  has  been  unconsciously  and  yet  admirably  done.  In 
Case  3600,  on  opening  the  abdomen,  a  diffuse  myomatous  thicken- 
ing was  found  in  the  posterior  uterine  wall.  It  was  considered  to 
be  only  a  myomatous  thickening,  and  a  wedge-shaped  piece  of  the 
growth  was  removed;  in  other  words,  a  partial  myomectomy  was 
performed  (Fig.  54). 

The  histological  picture  as  seen  in  Fig.  55  shows  that  the  growth 
was  a  typical  and  diffuse  adenomyoma  of  the  uterus.  The  patient 
made  a  good  recovery,  and  eleven  years  afterward,  in  response  to 
an  inquiry  as  to  her  condition,  said  that  she  had  been  greatly  bene- 
fited by  the  operation  and  that  she  was  in  perfect  health.  The  mass 
was  certainly  not  entirely  removed,  and  the  subsequent  history  con- 
firms what  was  indicated  by  the  histological  findings,  namely,  the 
benign  character  of  the  growth. 

In  Case  4415  we  were  also  dealing  with  a  diffuse  myomatous 
uterine  growth.  A  wedge,  5  by  2  cm.,  was  removed  through  the 
abdomen.  This  patient  also  recovered.  On  examination  the  growth 
proved  to  be  an  adenomyoma.  Here,  also,  notwithstanding  the 
fact  that  portions  of  the  growth  were  left  behind,  the  patient   was 

1Vod  Recklinghausen,  Friedrich:  Die  Adenomyome  und  Cystadenome  tier 
Uterus  und  Tubenwandung;   ihre  Abkunft  von   Resten  'It-  Wolff'schen  Kor 

Berlin.  1896. 

is; 


188 


ADENOMYOMA    OF    THE    UTERUS 


much  improved.  For  two  years  she  had  no  trouble,  but  since  then 
the  periods  have  been  longer,  and  sometimes  last  for  weeks.  She  has, 
however,  been  completely  relieved  of  pain  at  the  menstrual  periods. 

We  see,  therefore,  from  the  his- 
tological and  clinical  pictures  that 
these  growths  are  benign. 

Since  these  two  cases  were  pub- 
lished1 we  have  had  several  similar 
instances  under  observation. 


Fig.  54. — A  portion  of  a  diffuse  adeno- 

1IYOMA   OF   THE  POSTERIOR  "WALL  OF   THE 

uterus.      (Slightly  enlarged.) 

Gyn.-Path.  No.  777.  At  opera- 
tion the  posterior  uterine  wall  was  found 
much  thickened.  A  wedge  was  removed  and 
the  cut  surfaces  were  brought  together  as  in 
an  ordinary  myomectomy,  a  is  the  peri- 
toneal surface;  just  beneath  it  is  a  narrow 
zone  of  normal  muscle.  The  growth  presents 
the  typical  appearance  of  a  diffuse  myoma. 
Along  the  outer  margin  it  gradually  merges 
into  the  normal  muscle,  b  corresponds  to 
the  point  nearest  the  uterine  cavity.  The 
uterine  cavity  was  not  opened.  Scattered 
throughout  the  myoma  are  small  round  oval 
or  oblong  spaces.  Some  are  dilated  glands, 
others  cross-sections  of  small  blood-vessels. 
For  the  histological  findings  see  Fig.  55.  At 
the  time  the  operation  was  performed  we 
were  unfamiliar  with  these  adenomyomatous 
growths. 


CASES  GRAPHICALLY  ILLUSTRATING 
THE  BENIGN  CHARACTER  OF 
ADENOMYOMATA  OF  THE  UTERUS 

Gyn.  No.  3600.    Path.  No.  777. 
Diffuse  adenomyoma 
of    the    posterior   uter- 
ine   wall    (Figs.  54  and    55). 
Removal     of     a     wedge- 


shaped  portion  of  the 
growth.  Complete  re- 
lief from  former  symp- 
toms. 

G.  H.  W.,  married,  white,  aged 
twenty-five.  Admitted  June  24; 
discharged  July  20,  1895.  The 
patient  has  been  married  ten 
years,  but  has  never  been  pregnant.  Her  menses  began  at 
thirteen,  were  regular  and  always  associated  with  severe  pain, 
dull  and  grinding  in  character,  with  sharp  paroxysms  referred 
to  the  abdomen  and  in  the  back.  This  pain  has  been  growing- 
much  worse  recently  and  has  been  associated  with  nausea.  It 
is  only  present  during  the  periods.  The  flow  is  very  profuse 
and  is  growing  more  so.  It  is  occasionally  clotted.  The  patient 
has  a  slight  leucorrhceal  discharge. 

1  Cullen,  Thomas  S.:  Adenomyome  des  Uterus,  Berlin,  1903. 


PROGNOSIS 


89 


Two  months  ago  she  noticed  thai  the  abdomen  was  larger  than 
normal. 

Operation,  June  20,  1895.  Myomectomy.  A  myo- 
matous thickening  was  noted  in  the  posterior  wall.  This  thickening 
extended  from  the  cervix  to  the  fundus,  and  the  uterus  was  the  Bize 
of  that   of  a  three  months'  pregnancy.     A  wedge-shaped  piece  was 


/* 


&?« 


*  "& 


«**• 


X 

f 


— --c 


d 
Fig.  55. — Diffuse  ajdenomyoma.     (6  diameters.) 

G  yn.-Path.  No.  777.  The  section  is  taken  from  Fig.  54.  The  growth  under  the 
higher  power  was  recognized  as  a  diffuse  myoma.  At  a  and  a'  we  find  groups  <>f  glands  resembling 
uterine  glands  both  in  form  and  in  their  even  distribution.  They  are  embedded  in  a  definite 
stroma  which  separates  them  from  the  muscle.  Some  of  the  glands  in  the  islands  of  mucosa  show 
slight  branching.  At  c  the  glands  are  arranged  in  "goose  march"  fashion.  They  are  in  all  prob- 
ability sections  of  one  and  the  same  gland  which  has  been  much  convoluted.  At  ./one  of  the 
glands  is  moderately  dilated,  e  shows  a  more  marked  dilatation,  and  here  SO  much  tension  has 
taken  place  that  little  of  the  surrounding  stroma  remains.  /  corresponds  very  well  to  a  miniature 
uterine  cavity.  On  the  one  side  it  has  become  flattened  out  so  that  there  is  merely  a  layer  of 
epithelial  cells  and  a  faint  amount  of  stroma.  On  the  opposite  side  is  a  well  developed  mucosa. 
Isolated  glands  are  scattered  throughout  the  growth.  Without  exception  they  arc  surrounded  by 
the  characteristic  stroma  and  nearly  all  closely  resemble  uterine  glands.  The  cystic  dilatation  is 
to  be  expected  where  the  glands  are  subjected  to  the  myomatous  pressure. 

excised  from  the  posterior  wall  and  the  uterine  walls  were  brought 
together.  The  length  of  the  incision  in  the  uterus  was  S  cm.  The 
patient  made  a  satisfactory  recovery. 

January,  1907.  The  patient  is  perfectly  well  eleven  years  after 
operation. 

G  v  n  .    Path.    N  o  .    7  7  7  . — The   specimen    consists    of    sev- 


190  ADENOMYOMA    OF    THE    UTERUS 

eral  large  and  small  pieces  of  tumor.  All  of  the  tissue  is  pinkish- 
white  in  color,  firm  on  pressure,  and  apparently  composed  of  coarse 
fibres  arranged  in  interlacing  bundles  (Fig.  54). 

Histological  Examination  . — The  tissue  consists  of 
non-striped  muscle  fibres  cut  in  various  directions.  Scattered  here 
and  there  throughout  it  are  glands  occurring  singly  or  in  groups 
(Fig.  55).  They  are  lined  with  high  cylindrical  ciliated  epithelium 
and  are  surrounded  by  a  stroma  identical  with  that  of  the  uterine 
mucosa.  These  glands  are  precisely  similar  to  uterine  glands.  Some 
of  them  are  dilated. 

Diagnosis  . — Adenomyoma  uteri  diffusum  benignum. 

Gyn.  No.  4415.    Path.  No.  1207. 

Removal  of  a  wedge-shaped  piece  of  an 
adenomyoma  of  the  posterior  uterine  wall. 
Complete  cessation  of  the  previous  symp- 
toms for  two  years,  followed  again  by  pro- 
fuse   menstruation. 

I.  C.  R.,  white,  married,  aged  forty.  Admitted  May  28;  dis- 
charged July  11,  1896.  The  patient  has  been  married  eighteen 
years  and  has  never  been  pregnant.  The  menses  commenced  at 
twelve  and  were  regular  up  to  two  or  three  years  ago.  Since  that 
time  they  have  occurred  every  twenty-second  or  twenty-third  day 
The  flow  is  profuse,  dark  and  clotted,  and  associated  with  bearing- 
down  pains  in  the  abdomen  and  also  with  backache  and  pains  in 
the  legs.  Micturition  is  frequent  and  the  patient  has  a  constant 
feeling  of  pressure  on  the  bladder.  The  bowels  are  constipated.  She 
suffers  but  little  discomfort  except  at  her  menstrual  periods.  For 
the  past  year  she  has  noticed  a  slight  increase  in  the  abdominal 
girth. 

Operation,  June  1,  1896.  Myomectomy.  A  wedge- 
shaped  piece  of  the  diffusely  thickened  wall  was  removed;  also  a 
pedunculated  and  partly  cystic  myoma,  5  by  2  cm.  Convalescence 
was  interrupted  by  an  attack  of  phlebitis  and  one  of  pleurisy.  The 
pleurisy  developed  at  the  base  of  the  left  lung  and  persisted  for  nine 


PROGNOSIS  I'M 

days.     The  phlebitis  developed  in  the  femora]  vein  on  the  twenty- 
second  day.      The  patient   made  a  satisfactory  recovery. 

She  remained  well  for  two  years  and  then  again  began  to  have 

profuse  menstruation. 

(;  y  n  .  Path.  No.  1207  . — The  specimen  consists  of  a 
subperitoneal  myoma  and  several  fragments  of  an  interstitial 
myoma. 

The  subperitoneal  myomatous  nodule  measures  5  by  5  by  4.5  cm. ; 
it  is  pinkish  in  color  and  on  pressure  is  firm.  Springing  from  its 
surface  is  a  cyst  2.5  cm.  in  diameter.  This  is  whitish  in  color,  its 
walls  are  semi-transparent,  and  it  contains  clear  yellow  fluid.  On 
section  the  nodule  presents  the  typical  myomatous  appearance.  The 
walls  of  the  cyst  average  3  mm.  in  thickness  and  are  rather  soft. 
The  inner  surface  on  one  side  is  smooth;  on  the  other,  roughened. 
The  cyst  appears  to  be  a  portion  of  the  myoma  that  has  undergone 
degeneration.  The  tumor  also  contains  another  area  of  degeneral  i<  m 
measuring  2.5  by  1  cm. 

The  fragments  of  the  interstitial  myoma  are  nine  in  number  and 
the  largest  measures  4  by  3  by  1.5  cm.  All  of  them  are  composed  of 
bundles  of  coarse  fibres  forming  an  irregular  network,  in  the  meshes 
of  which  are  minute  cystic  areas.  One  of  these  pieces  is  covered 
with  peritoneum  and  the  outer  covering  of  normal  muscle  at  that  point 
is  4  mm.  in  thickness.  The  line  of  junction  between  the  myomatous 
tissue  and  the  normal  muscle  is  sharply  denned,  but  it  is  impossible 
to  shell  the  tumor  out  at  any  point. 

Histological  Examination.  The  subperitoneal 
nodule  is  composed  of  non-striped  muscle  fibres,  which  in  places  have 
undergone  moderate  hyaline  degeneration,  at  other  points  complete 
hyaline  transformation.  The  line  of  demarcation  between  the  in- 
tact muscle  fibres  and  the  degenerated  portions  is  abrupt. 

The  interstitial  myomatous  tissue  is  also  composed  of  inter- 
lacing bundles  of  smooth  muscle,  but  shows  very  little  tendency 
toward  hyaline  degeneration.  Scattered  between  the  muscle  bundles 
almost  to  the  peritoneal  covering  are  groups  of  glands  or  single  gland- 
like spaces. 


192  ADENOMYOMA    OF    THE    UTERUS 

These  glands  are  small  and  round  and  sometimes  send  off  one  or 
more  branches;  some  are  dilated,  reaching  1  to  2  mm.  in  diameter. 
They  are  lined  with  cylindrical  epithelium,  having  oval  vesicular 
nuclei  situated  in  the  centres  of  the  cells.  Surrounding  the  'glands 
and  separating  them  from  the  muscle  is  a  moderate  amount  of 
stroma  consisting  of  oval  or  elongate  cells  having  oval  vesicular 
nuclei.  These  cells  are  identical  with  the  stroma  cells  of  the  uterine 
mucosa  and  the  glands  are  in  every  respect  similar  to  those  of  the 
uterus.  The  myomatous  tissue  has  a  moderately  abundant  blood- 
supply. 

Diagnosis  . — Subperitoneal  myoma.  Interstitial  adeno- 
mvoma  of  the  uterus. 


CHAPTER  XIII 

ORIGIN  OF  ADENOMYOMATA  OF  THE  UTERUS 

In  L896  von  Recklinghausen  reviewed  the  literature  of  adeno- 
myomata  and  added  many  new  cases.  After  a  careful  consideration 
of  all,  he  concluded  that  in  the  vast  majority  of  instances  the  glandu- 
lar elements  were  derivatives  of  the  Wolffian  duct.  This  opinion  was 
based  upon  the  supposed  close  analogy  between  the  elements  of  the 
Wolffian  duct  and  the  glandular  structures  present  in  adenomyomata 
of  the  uterus.  In  only  one  case  was  he  certain  that  the  glands  were 
due  to  down-growths  of  the  uterine  mucosa.  This  case  of  von  Reck- 
linghausen was  included  in  the  appendix  to  his  most  instructive 
treatise.  Since  his  publication  appeared,  much  attention  has  been 
devoted  to  this  subject  and  quite  a  number  of  new  cases  have  been 
reported.  Many  writers  have  espoused  von  Recklinghausen's  theory, 
but  not  a  few  have  claimed  that  nearly  all,  if  not  all,  of  these  cases 
owe  their  origin  to  the  uterine  mucosa  or  to  a  portion  of  Midler's 
duct.  It  would  be  unnecessary  for  us  to  review  at  length  this  lively 
controversy,  but  to  those  wishing  the  full  details  we  would  recom- 
mend the  careful  presentation  of  the  subject  as  given  by  von  Reck- 
linghausen,1 Meyer,2  Pick,3  and  Kossmann.4 

In  my  previous  publication5  I  reported  nineteen  cases  of  diffuse 
adenomyoma  and  pointed  out  that  in  the  majority  of  these  cases  the 
process  was  still  limited  to  the  uterus,  thus  enabling  us  to  determine 
definitely  the  origin  of  the  glands  in  most  of  the  rases.     Since  then 

1  "\'«>ii  Recklinghausen,  Friedrich:  Die  Adenomyome  und  Cystadenome  der 
Uterus-  und  Tubonwandung;  ihre  Abkunfl  von  Etesteo  des  Wolff'schen  Korpers. 
Berlin,  L896. 

'-'  Meyer:  Ueber  Driisen,  Cysten  und  Adenome  im  Myometrium  bei  Erwachsenen. 
Ztschr.  I',  (icl).  u.  Gyn.,  L900,  Bd.  xlvii,  S.  618;   xlviii,  S.  130  u.  329. 

3  Pick:  Archiv.  Fur  Gyn.,  Bd.  liv. 

*  Kossmann,  B.:  Die  Abstammung  der  Driiseneinschliisse  in  den  Adenomyomen 
des  Uterus  und  der  Tuben.     Arch.  f.  Gynaek.,  Bd.  liv.  s.  359. 

5  Cullen,  Thomas  S. :   Adeno-Myoma des  Uterus,  Berlin.  1903. 
13  L93 


194  ADENOMYOMA    OF    THE    UTERUS 

we  have  subjected  each  myomatous  uterus  to  the  most  careful  scru- 
tiny, and  wherever  adenomyoma  was  suspected  we  have  had  very 
large  sections  made  from  many  parts  of  the  uterine  cavity.  If  adeno- 
myoma was  present  and  no  connection  between  the  glands  in  the 
depth  and  the  uterine  mucosa  could  be  detected,  we  kept  on  cutting 
more  tissue,  until  finally  in  the  vast  majority  of  the  cases  we  found 
that  the  gland  elements  were  derivatives  of  the  uterine  mucosa.  I 
have  been  greatly  helped  in  this  work  by  Mr.  Benjamin  O.  McCleary, 
our  laboratory  assistant. 

We  have  had  fifty  uncomplicated  cases  of  diffuse  adenomyoma 
of  the  uterus,  some  very  extensive,  others  in  their  early  stages.  In 
every  one  of  these  cases  we  have  been  able  by  persistent  search  to 
trace  the  uterine  mucosa  into  the  myomatous  tissue.  In  other  words, 
islands  of  mucosa  in  the  diffuse  myomata  originated  from  the  mu- 
cosa lining  the  uterine  cavity  in  every  case.  Any  one  can  verify 
this  statement  for  himself  by  studying  the  pathological  description 
in  each  case. 

In  six  other  cases  there  was  squamous-cell  carcinoma  of  the 
cervix  and  diffuse  adenomyoma  of  the  body.  In  five  of  the  six  cases 
the  origin  of  the  gland  elements  in  the  myoma  could  be  traced  to  the 
mucosa.  In  one  case  (Gyn.  9971),  where  the  process  was  a  rather 
indefinite  one,  it  was  impossible  to  show  the  origin  of  the  glands  from 
the  mucosa. 

We  thus  see  that  in  fifty -five  out  of  fifty-six  cases  of  diffuse  adeno- 
myoma of  the  body  of  the  uterus  the  gland  elements  were  shown  to 
be  derived  in  part  at  least  from  the  uterine  mucosa. 

In  Gyn.  8438  and  also  in  Sanitarium  No.  1852  diffuse  adenomyoma 
of  the  body  and  adenocarcinoma  of  the  body  were  present.  In  both 
of  these  the  uterine  mucosa  has  been  destroyed,  and  the  carcinoma- 
tous growth  so  overshadowed  the  picture  that  the  origin  of  the  glands 
in  the  myomatous  growth  was  naturally  totally  obscured. 

SUBPERITONEAL  ADENOMYOMATA 

In  eight  cases  we  have  found  subperitoneal  adenomyomata.  In 
Case  8647  there  was  a  large  subperitoneal  adenomyoma,  and  exami- 


ORIGIN    OF    ADENOMYOMATA    OF   THE    UTERI  -  195 

nation  of  the  uterine  mucosa  showed  that  the  glands  extended  L.5  nun. 
into  tlie  muscle.  Of  course,  no  continuity  will)  the  subperitoneal 
nodule  could  be  traced.  In  Case  3293  subperitoneal  cysts  of  an 
adenomyomatous  type  were  found,  but  in  this  case  the  uterine  muroa 
was  normal.  In  Sanitarium  Xo.  1872,  in  which  the  most  typical 
adenomyoma  lay  perfectly  free  from  the  uterus,  being  attached  to  the 
utero-ovarian  ligament  (Fig.  41),  the  uterine  mucosa  extended  into 
the  muscle  and  the  uterus  was  also  the  seat  of  discrete  myomatous 
nodules.  In  Gyn.  5782  the  adenomyomatous  nodule  was  small  and 
the  uterine  mucosa  had  been  completely  destroyed  by  the  adeno- 
carcinoma. In  the  remaining  case  of  subperitoneal  adenomyoma  the 
nodule  alone  was  removed,  and  we  had  no  chance  to  examine  the 
uterine  mucosa  to  determine  if  any  continuity  with  the  adenomyoma 
persisted. 

SUBMUCOUS  ADENOMYOMATA 

We  have  had  seven  cases  of  submucous  adenomyomata.  Some 
consisted  of  diffuse  myomatous  growths  containing  only  a  few  small 
glands.  In  others  the  glands  had  become  cvstic;  in  one  case  the 
myoma  was  riddled  with  miniature  uterine  cavities.  In  this  case 
the  direct  continuity  with  the  uterine  mucosa  was  readily  established. 

Where  the  uterine  glands  are  seen  penetrating  the  myomatous 
muscle,  as  in  Figs.  2,  3,  6,  15,  and  30,  there  is  no  question  as  to  their 
being  derivatives  of  the  uterine  mucosa,  and,  as  will  be  seen  from  a 
study  of  our  cases,  in  the  majority  of  which  the  uterus  was  removed. 
the  mucous-membrane  origin  was  established.  This  fact  is  very 
significant  when  compared  with  the  figures  of  those  claiming  the 
Wolffian  duct  origin.  With  the  increase  in  thickness  and  the  ir- 
regular growth  of  the  diffuse  myoma  it  is  very  natural  that  the  con- 
tinuity of  the  uterine  glands  into  the  depth  should  be  lost  after  a 
time,  as  is  evidenced  by  the  formation  of  cysts.  It  is  not  necessary 
that  the  uterine  glands  be  traced  by  continuity  to  establish  the  mucous- 
membrane  origin.  The  islands  of  glands  lying  deep  down  in  the 
myomatous  muscle  correspond  identically  with  those  seen  in  cases  in 


196  ADENOMYOMA   OF   THE    UTERUS 

which  the  continuity  is  traceable,  and  moreover  they  are  precisely 
the  same  as  in  normal  uterine  mucosa.  Furthermore,  they  are  sur- 
rounded by  a  stroma  identical  with  that  surrounding  the  uterine 
glands.  In  some  cases  miniature  uterine  cavities  are  scattered 
throughout  the  myoma.  Fig.  22,  taken  from  a  cavity  near  the  peri- 
toneal surface  of  an  adenomyoma,  could  not  be  distinguished  from 
normal  uterine  mucosa.  From  the  uterine  mucosa  there  is  a  periodic 
hemorrhage  every  month.  According  to  Hartz,1  Sanger,  when  speak- 
ing to  his  students  of  the  uterine  mucosa,  said :  "  This  is  no  simple 
mucous  membrane,  but  is  an  organ  which  has  an  important  function 
to  fulfil."  With  Sanger's  view  I  am  in  thorough  accord.  In  no 
other  part  of  the  body  do  we  find  a  mucosa  with  a  similar  function, 
and  nowhere  else  do  we  meet  with  such  histological  peculiarities. 
Now,  if  portions  of  this  uterine  mucosa  be  far  removed  from  the 
parent  mucosa,  we  should  still  expect  them  to  retain  their  function, 
and  this  they  do.  In  nearly  every  instance  in  which  cyst  spaces  are 
present,  the  cavities  are,  in  part  or  almost  completely,  filled  with 
blood;  and  even  in  the  small  and  undilated  glands  blood  is  fre- 
quently present,  or  the  epithelial  cells  contain  blood  pigment,  the 
remnants  of  old  hemorrhages.  It  is  natural  that  the  cysts  in  the 
uterine  walls  should  remain  small,  as  they  are  compressed  by  the 
muscle;  on  the  other  hand,  when  they  have  once  become  subperi- 
toneal they  may  dilate  until  they  can  contain  several  litres  of  blood, 
although  even  in  these  cases  they  still  show  the  evidence  of  the 
menstrual  phenomenon  as  seen  in  their  chocolate-colored  contents. 
In  the  solid  portions  of  these  growths  islands  of  typical  uterine  mu- 
cosa are  still  demonstrable.  It  is  so  easy  to  understand  how  inter- 
stitial myomata  become  subperitoneal  or  submucous,  and  yet  in 
considering  the  subsequent  history  of  adenomyoma  the  majority  of 
authors  have  forgotten  to  apply  the  same  principle.  When  the 
growth  becomes  subperitoneal,  we  should  expect  its  glandular  ele- 
ments to  gradually  lose  their  continuity  with  those  of  the  mucosa, 
and  such  is  the  case.     Hence  the  confusion  as  to  their  origin.     Case 

1  Hartz,  A.  L.:  Neuere  Arbeiten  ueber  die  mesonephrischen  Geschwiilste.      Mon- 
atsschrift  f.  Geburtshulfe  unci  ( lynaekologie,  1901,  Bd.  xiii,  S.  95  u.  244 


ORIGIN    OF    ADENOMYOMATA    OF    THE    I  TER1  -  19*3 

2  of  Broils'  and  Kroenig's  case  illustrate  very  well  the  intraligament- 
ary  variety.  In  Kroenig's  case  we  have  all  the  elements  of  normal 
uterine  mucosa,  and  also  large  cysts.  In  Breus'  case  we  find  the 
same,  but  fortunately  the  communication  between  the  uterine 
mucosa  and  the  cystic  tumor  still  persists,  showing  beyond  doubt 
that  the  gland  elements  in  this  case  were  from  the  uterine  mucosa. 

A  definite  example  of  a  portion  of  a  diffuse  adenomyoma  becom- 
ing subperitoneal  is  furnished  by  Lockstaedt.1  The  adenomyoma 
occupied  the  posterior  wall  and  right  side,  and  in  the  gross  specimen 
it  was  possible,  in  at  least  five  places,  to  see  the  mucosa  extending 
deeply  into  the  myoma.  In  this  case  there  was  a  subperitoneal 
adenomyoma,  the  size  of  a  cherry,  that  by  its  pedicle  was  in  direct 
communication  with  the  diffuse  growth,  so  that  its  glands  were  un- 
doubtedly derivatives  of  those  of  the  uterine  mucosa. 

Were  we  in  need  of  still  further  proof  that  these  islands  of  mucosa 
are  identical  with  normal  uterine  mucosa  the  case  reported  by  J. 
Whitridge  Williams'  would  certainly  tend  to  convince  the  most 
skeptical.  In  examining  the  uterus  of  a  patient  entering  the  hos- 
pital in  a  desperate  condition  and  dying  two  hours  after  labor  he 
found  that  it  was  the  seat  of  a  diffuse  adenomyoma  and  that  the 
stroma  of  these  islands  had  been  converted  into  typical  decidua. 

A  somewhat  similar  decidual  formation  is  reported  on  page  247. 
In  this  case  I  found  a  subperitoneal  myoma  near  the  right  uterine 
horn.  On  the  left  side  was  an  unruptured  tubal  pregnancy.  The 
stroma  of  the  adenomyoma  had  been  in  part  converted  into  decidual 
cells,  although  the  adenomyoma  was  at  least  9  cm.  away  from  the 
tubal  pregnane)'. 

'  Breus,  Carl:  Ueber  wahre  epithelfiihrende  Cystenbildung  in  Uterus-Myomen. 
Leipzig  und  Wien,  L894. 

-  Kroenig,B.:  Kin  Retroperitoneal  ireleirenos  voluminoses  Polycystom  entstanden 
aus  Etesten  des  Wolff'schen  Kdrpers.     Beitrage  zur  I  leb.  u.  Gyn.,  L901,  Bd.  iv,S.  61. 

sLockstaedt:  Ueber  Vbrkommen  und  Bedeutung  von Driisenschlauchen  Lndeo 
Myomen  <!<•>  Uterus.     Monatschr.  f.  Geb.  u.  Gyn.,  L898,  Bd.  vii,  S.  L88. 

'Williams,  J.  Whitridge:  Decidual  Formation  Throughoul  the  Uterine  Muscu- 
laris:  A  Contribution  to  the  Origin  of  Adenomyoma  <>t'  the  Uterus.  Transactions 
of  the  Southern  Surgical  Association,  1904,  vol.  xvii. 


198  ADENOMYOMA    OF    THE    UTERUS 

RESUME 

In  the  examination  of  fifty  uncomplicated  diffuse  adenomyomata 
of  the  uterus  the  mucous-membrane  origin  of  the  glands  could  be 
traced  in  every  case.  In  six  additional  cases  where  squamous-cell 
carcinoma  of  the  cervix  complicated  adenomyoma  of  the  body  the 
continuity  was  established  in  five  cases.  In  the  two  remaining  cases 
of  diffuse  adenomyoma  of  the  body  the  clue  as  to  the  origin  of  the 
glands  was  destroyed  by  the  presence  of  adenocarcinoma  of  the  body. 
Thus  in  only  one  case  out  of  fifty-six  in  which  we  expected  to  find 
the  glands  originating  from  the  mucosa,  if  our  view  as  expressed  in 
1896  was  correct,  did  we  fail  to  find  it  substantiated.  In  the  re- 
maining fifteen  cases  of  subperitoneal  or  submucous  adenomyomata 
we  would  naturally  not  expect  to  trace  the  relationship  between  the 
mucosa  and  the  glands  in  the  myoma ;  nevertheless  in  one  case,  Gyn. 
No.  10,314,  the  mucosa  had  literally  flowed  into  the  myoma.  It  will 
thus  be  seen  that  when  we  include  adenomyomata  of  every  kind, 
out  of  subperitoneal,  submucous,  or  diffuse,  we  have  been  able  in 
fifty-six  out  of  seventy -three  cases  to  trace  the  origin  of  the  gland 
elements  to  the  uterine  mucosa. 

All  adenomyomata  of  the  uterus  in  which  the  gland  elements  are 
similar  to  those  of  the  uterine  mucosa,  and  are  surrounded  by  stroma 
characteristic  of  that  surrounding  the  normal  uterine  glands,  owe 
their  glandular  origin  to  the  uterine  mucosa  or  to  Muller's  duct,  no 
matter  whether  they  be  interstitial,  subperitoneal,  or  intraligament- 
ary,  whether  solid  or  cystic.1 

1  Frequently  there  are  small  cyst-like  spaces  apparently  just  beneath  the  per- 
itoneal surface  of  the  uterus.  These  are  lined  with  a  single  layer  of  cuboidal  cells 
and  rest  directly  on  the  muscle.  They  are  due  to  depressions  from  the  peritoneal 
surface,  but  at  another  level.  In  favorable  sections  their  continuity  with  the  per- 
itoneal cavity  can  be  traced.  Meyer  has  recently  pointed  them  out.  We  thoroughly 
agree  with  his  findings,  and  have  also  often  met  with  them  on  the  under  or  protected 
side  of  tubal  adhesions  or  lining  the  small  depressions  occurring  on  the  surface  of 
the  ovary.     The  peritoneal  cells,  where  protected,  tend  to  become  cuboidal. 


CHAPTER  XIV 

CAUSES  OF  ADENOMYOMA  OF  THE  UTERUS 

We  thought  that  possibly  pregnancy  with  its  incident  extensive 
stretching  of  the  uterus  might  leave  crevices  into  which  the  mucosa 
could  later  flow.  A  reference  to  page  174,  however,  show-  thai 
fifteen  out  of  forty-nine  patients  had  never  been  pregnant,  so  that 
even  were  this  a  possible  cause  we  must  find  another  solution  for 
those  cases  in  which  the  adenomyoma  had  developed  in  a  uterus  that 
had  never  been  subjected  to  the  stret chins;  incident  to  pregnancy. 
From  a  study  of  the  clinical  history  we  gain  no  clue  as  to  the  causation. 

Histological  examination  in  a  number  of  cases  gives  a  decided 
impression  that  the  diffuse  myomatous  growth  is  the  primary  factor. 
In  these  cases  there  is  a  myomatous  tendency,  as  evidenced  by  the 
almost  constant  presence  of  discrete  myomatous  nodules.  The 
uterine  mucosa  flows  into  the  chinks  of  the  diffuse  myomatous 
growth.  As  has  been  pointed  out  so  frequently,  the  surface  of  the 
mucosa  is  perfectly  regular  and  intact  and  the  uterine  glands  are  in 
no  wise  altered.  The  only  pathological  change,  in  such  cases,  lies 
in  the  extension  of  normal  glands  into  the  crevices  throughout  the 
myomatous  growth. 


[99 


CHAPTER  XV 

HYPERTROPHY  OF   THE   CERVIX   AND   DIFFUSE   ADENOMYOMA   OF 
THE  BODY  OF  THE  UTERUS 

In  the  examination  of  thousands  of  specimens  this  is  the  most 
unique  we  have  ever  encountered.  There  is  a  marked  increase 
in  the  size  of  the  cervix  due  to  simple  hypertrophy,  while  the  fundus 
has  kept  pace  by  the  development  of  an  adenomyoma.  We  ac- 
cordingly have  a  uterus  which,  although  greatly  enlarged,  still  has 
retained  its  relatively  normal  proportions. 

Gyn.  No.  6240.    Path.  No.  2532. 

Very  extensive  hypertrophy  of  the  cervix; 
diffuse  adenomyoma  of  the  anterior  and  poste- 
rior uterine  walls  (Fig.  56)  with  glands  origin- 
ating from  the  uterine  mucosa. 

L.  C,  aged  fifty-two,  married,  white.  Admitted  July  15, 1898 ;  dis- 
charged September  20,  1898.  Complaint:  Prolapsus  of  the  uterus 
and  uterine  hemorrhage;  pain  in  the  abdomen.  Her  menses  began 
at  sixteen  and  were  profuse,  occurring  every  three  weeks  and  lasting 
from  seven  to  eight  days.  They  have  been  irregular  for  the  last  two 
years  and  have  been  more  profuse,  the  bleeding  assuming  the  pro- 
portions of  a  hemorrhage.  There  has  been  a  leucorrhcea  and  pro- 
fuse vaginal  discharge  for  many  years.  The  patient  has  had  nine 
children,  the  eldest  thirty  years,  the  youngest  fourteen.  On  examina- 
tion a  large  tumor  is  found  projecting  through  the  outlet — apparently 

Fig.  56. — Very   extensive   hypertrophy  of  the   cervix,     discrete   myoma   and    diffuse 

ADENOMYOMA  OF  THE  BODY  OF  THE  UTERUS.   (Natural  size.) 

Gyn. -Path.  No.  2532.  We  have  purposely  had  the  specimen  drawn  the  natural  size 
so  that  an  accurate  idea  of  the  great  and  almost  uniform  increase  in  size  of  this  organ  is  obtained. 
The  cervix  shows  a  very  extensive  hypertrophy,  but  is  everywhere  intact.  A  few  of  the  cervical 
glands  are  dilated.  At  the  fundus  the  subperitoneal  myoma  is  seen.  The  uterine  walls  show 
considerable  diffuse  myomatous  thickening,  and  scattered  throughout  them  are  seen  islands  of 
typical  uterine  mucosa.  The  continuity  between  them  and  the  parent  mucosa  has  in  places  been 
traced. 

200 


ASSOCIATED    in  PERTROPH?    OF    <  |.I;\  i\ 


2( 


Fig.  56. 


202  ADENOMYOMA    OF    THE    UTERUS 

a  complete  prolapsus.  The  cervix  is  very  prominent,  7  cm.  in  diam- 
eter and  apparently  ulcerated. 

Operation  . — Vaginal  hysterectomy;  repair  of  perineum. 

Path.  No.  2532  . — The  specimen  consists  of  the  uterus, 
tubes  and  ovaries  intact.  The  uterus  is  exceedingly  long,  being 
16  cm.  in  length,  7  cm.  in  breadth,  and  4  cm.  in  its  antero- 
posterior diameters  (Fig.  56).  It  is  free  from  adhesions.  The  pos- 
terior surface  presents  a  more  or  less  even  appearance,  while  the 
anterior  surface  is  round  and  shows  a  nodular  mass  just  beneath  the 
attachment  of  the  left  tube.  The  great  length  of  the 
uterus  is  due  to  hypertrophy  of  the  cervix, 
as  the  cervical  portion  is  fully  8  cm.  long. 
The  outer  portion  of  the  cervix  is  rough  and  nodular  and  everywhere 
covered  with  mucosa.  The  mucosa  lining  the  cervix  is  gathered  up 
into  folds.  The  mucous  membrane  of  the  body  of  the  uterus  in  some 
places  reaches  3  mm.  in  thickness.  Both  uterine  walls  present  a 
coarse  myomatous  striation. 

Histological  Examination  . — The  hypertrophy  of 
the  cervix  is  confined  chiefly  to  the  over-growth  of  the  stroma. 
The  surface  epithelium  is  everywhere  intact.  The  papillae  are  in 
places  long  and  branching  and  the  overlying  epithelium  shows  more 
hornification  than  usual. 

Sections  from  the  anterior  wall  show  that  the  mucous  membrane 
is  normal,  but  slightly  thicker  than  usual.  The  wall  is  com- 
posed of  diffuse  myomatous  tissue  and  scat- 
tered throughout  it  are  typical  islands  of 
uterine  mucosa.  In  a  few  places  direct  con- 
tinuity from  the  mucosa  into  the  depth  can 
be  traced.  The  posterior  wall  also  shows  normal  uterine 
mucosa  with  some  thickening.  Here  there  is  likewise  a  diffuse 
adenomyoma.  The  islands  of  mucosa  throughout  the  myoma 
closely  resemble  normal  mucosa.  In  many  places  extension  of  the 
mucosa  into  the  depth  can  be  traced. 

Diagnosis  . — Very  extensive  hypertrophy  of  the  cervix ; 
diffuse  adenomyoma  of  both  the  anterior  and  posterior  uterine  walls. 


CHAPTER  XVI 

ADENOMYOMA  IN  ONE  HORN  OF  A  BICORNATE  UTERUS 

It  is  interesting  to  find  one  horn  of  a  bicornate  uterus  the  seat  of 
an  adenomyoma.  Whether  the  opposite  horn  was  likewise  involved 
we  cannot  say,  as  the  uterus  was  not  removed.  From  a  clinical 
standpoint  it  is  also  instructive,  as  in  this  case  there  was  absolutely 
no  connection  between  the  vagina  and  the  uterine  cavity,  there 
being  practically  no  cervix.  The  condition  in  this  case  absolutely 
excludes  any  possibility  that  pregnancy  has  necessarily  any  causal 
relation  to  the  development  of  the  adenomyoma. 

Gyn.  No.  10,516.    Path  No.  6764. 

Early  adenomyoma  in  the  left  rudiment  a  r  y 
horn  of  a  bicornate  uterus  ( Fig.  57),  the  g  1  a  n  d  s 
coming   from  the  uterine  mucosa. 

V.  P.,  black,  aged  twenty-four,  married.  Admitted  May  27. 
1903;  discharged  June  25,  1903.  Complaint:  Absence  of  menstrua- 
tion. The  menses  did  not  commence  until  she  was  twenty-one. 
Then  there  was  just  a  slight  stain  once,  and  none  since.  There 
has  been  severe  pain  in  the  left  side  and  back  every  month  for  the  past 
nine  years.  She  was  married  at  twenty-one,  but  has  had  no  children. 
On  ether  examination  a  normal  vagina  was  found  extending  in- 
ward for  5  cm.,  but  no  apparent  opening  could  be  made  out  between 
the  vagina  and  the  pelvic  organs  above.  Bimanual  examination 
of  the  left  side  showed  a  uterus  apparently  larger  than  normal.  The 
cervix  was  separated  from  the  vagina  by  a  distance  of  at  least  1  or  2 
cm.  and  apparently  was  not  connected  with  it  by  adhesions  or  any 
bands  of  tissue.     The  cervix  projected  to  the  left. 

Operation,  June  4,  1903.  An  attempt  was  made  to 
form  a  new  cervical  canal,  but  this  was  given  up  because  no  connec- 
tion could  be  made  out   between  the  cervix   and   body,  and   also 

203 


204  ADENOMYOMA  OF  THE  UTERUS 

because  the  external  os  was  not  patulous.  Through  the  abdominal 
incision  the  following  conditions  were  made  out :  On  the  left  side  was 
a  small  rudimentary  uterus,  3  by  1.5  cm.  There  was  no  cervix  and 
the  organ  was  directly  connected  with  a  band  of  tissue,  the  latter  in 
turn  being  connected  with  the  cervix  on  the  right  side.  Above  the 
uterus  was  a  large  flattened  tube  with  a  normal  fimbriated  extremity 
and  a  normal  ovary.  On  the  right  side  the  uterus  was  well  developed 
and  a  little  larger  than  normal.  The  cervix  was  poorly  formed  and 
had  no  external  opening.  The  tube  on  this  side  had  a  normal  fim- 
briated end  and  the  ovary  was  normal.     There  were  a  number  of 


A  V 

'bp\ 

V7'  "M.1? 

V  v 

r~ n 

V,  > 

i'-j 

/    \ 

:            V 

/ 

,•-  Vaj.     \ 

Fig.  57. — Adenomyoma  in  one  horn  of  a  bicornate  uterus.     (|  natural  size.) 

Gyn.-Path.  6764.  The  left  horn,  which  was  removed,  is  sketched,  but  the  right 
horn  is  merely  outlined.  In  this  case  there  was  no  trace  of  any  connection  between  either  uterine 
horn  and  the  vagina. 

adhesions  to  the  upper  part  of  the  fundus  and  to  the  ovary,  and 
several  cysts  containing  clear  fluid.  Owing  to  the  condition  of  the 
cornu  on  the  left  side,  it  and  its  appendages  were  removed.  The 
patient  made  an  uninterrupted  recovery. 

Path.  No.  6764  .—The  globular  body  of  the  uterus 
is  5  cm.  in  diameter  and  covered  with  adhesions  (Fig.  57). 
To  it  is  attached  a  small  left  tube  5  cm.  long,  apparently  normal,  and 
an  ovary  measuring  3  by  2  by  1  cm.  The  lower  third  of  the  body 
of  the  uterus  contains  no  uterine  cavity.  In  the  upper  third  is  seen 
a  cavity  1  cm.  long.     The  lining  mucosa  apparently  shows  no  change. 


ADENOMYOMA    IN    ONE    CORNU    OF    A    BICORNATE    I  TER1  8        205 

On  h  i  s  t  o  1  o  g  i  c  a  1  e  x  a  m  i  n  a  I  i  o  n  i  be  uterine  mucosa 
is  found  considerably  thickened  and  the  skein-like  arrangement  of 
the  glands  is  particularly  well  marked.  Seal  tered  every- 
where throu  g  li  out  t  li  e  u  t e  r  i  ii  e  w  all.  particu- 
lar! y  a  1)  u  n  d  a  n  I  i  n  t  h  e  v  i  e  i  n  i  t  y  o  i*  1  li  e  in  u  c  0  8  a  . 
are  islands  of  uterine  m  u  c  o  s  a  .  These  somet  imea 
consist  of  large  areas  of  mucous  membrane  and  sometimes  of  a  single 
gland  surrounded  by  stroma  and  often  much  dilated.  The  muscle 
shows  just  the  faintest  tendency  toward  myomatous  transformation. 
This  is  more  evident  macroscopically  than  microscopically.  W  i  t  h 
the  naked  eye  the  uterine  mucosa  can  he 
traced  directly  into  the  d  e  p  t  h  in  places  f  o  r  a 
distance  of  3  mm.  We  have  here  a  diffuse  adenomyoma  in 
which  the  glands  play  the  major  role.  It  is  particularly  interest  ing  to 
find  an  adenomyoma  in  one  half  of  a  bicornate  uterus.  The  histological 
picture  in  this  case  would  lead  one  to  infer  that  the  glands  first  existed  I 
and  that  the  myomatous  change  was  a  secondary  phenomenon. 
This  is  the  first  case  that  has  suggested  this  origin  to  us. 


CHAPTER  XVII 

DIFFUSE  ADENOMYOMA  OF  THE  BODY  OF  THE  UTERUS  OCCURRING 
IN  CASES  OF  SQUAMOUS-CELL  CARCINOMA  OF  THE  CERVIX 

Since  the  appearance  in  1903  of  a  previous  communication,1  in 
which  I  reported  a  case  of  squamous-cell  carcinoma  of  the  cervix 
associated  with  diffuse  adenomyoma  of  the  body  of  the  uterus,  I 
have  examined  five  similar  cases.  The  simultaneous  occurrence  of 
both  these  processes  in  six  cases  in  the  records  of  one  laboratory 
certainly  indicates  that  the  coexistence  of  these  two  diseases  is  no 
rarity.  When  we  see  what  a  large  number  of  adenomyomata  have 
been  detected  when  the  uteri  are  carefully  and  systematically  ex- 
amined, and  knowing  how  wide-spread  is  squamous-cell  carcinoma 
of  the  cervix,  it  is  little  wonder  that  these  two  processes  are  fre- 
quently found  in  the  same  uterus.  The  symptoms  of  the  carcinoma 
of  the  cervix  would  naturally  completely  overshadow  those  of  the 
adenomyoma.  Consequently  the  marked  extension  of  the  uterine 
glands  into  the  depth  would  not  be  suspected  until  after  removal 
of  the  uterus. 

Gyn.  No.  12,918.    Path.  No.  9841. 

Squamous-cell  carcinoma  of  the  cervix; 
diffuse  adenomyoma  of  the  uterine  walls  with 
direct  extension  of  the  uterine  mucosa  into 
the  depth   (Fig.  58). 

H.  G.,  married,  aged  forty-two,  black.  Admitted  May  9,  1906; 
discharged  June  2,  1906.  The  patient  has  been  married  twenty-four 
years  and  has  had  four  children,  the  oldest  nineteen,  the  youngest 
fifteen.  The  clinical  history  is  of  little  importance,  as  the  symptoms 
of  the  carcinoma  of  the  cervix  and  adenomyoma  of  the  body  merge 
so  imperceptibly  one  into  the  other. 

1  Cullen,  Thomas  S.:  Adenomyoms  des  Uterus,  Berlin,  1903. 

206 


ASSOCIATED    SQUAMOUS-CELL    CARCINOMA    OF    CERVIX 


207 


Operation.     Pan-hysterectomy.      The   entire   growth   was 
apparently  not   removed.     The  appendages  were  adherenl   to  the 


T" 


MM 


'■»■>-*•; 


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'rr:~ 


b  B 

Fig.  58.     I  >iffuse  adenomyom  \  i\  thb  bodt  of  THE  i  i  ERi  s.     (6  diameters. 

G  y  n.-Path.  9841.  The  section  is  From  the  upper  part  of  the  uterus,  a  indicates  the 
ut iM-ine  cavity  and  b  and  b'  the  normal  thickness  of  i  he  mucosa.  The  surface  epithelium  is  intact 
and  the  glands  are  of  the  normal  appearance,  but  the  mucosa  is  everywhere  flowing  into  the  under- 
lying myomatous  muscle,  as  is  particularly  well  seen  at  C,  d,  and  i  .     Section-  at  another  level  would 

show  that  the  apparently  isolated  islands  /  and  g  are  also  continuous  with  the  mucosa  lining  the 
uterine  cavity. 

posterior  surface  of  the  uterus  and  were  enlarged.     The  patienl  made 

a  very  satisfactory  recovery.     Her  highesl   post -operative  tempera- 
ture was  101.8°  F. 


208  ADENOMYOMA  OF  THE  UTERUS 

Path.  No.  9841  . — The  specimen  consists  of  the  uterus 
entire.  It'  is  10  cm.  in  length.  The  cervical  portion  presents  a 
worm-eaten  appearance  and  this  growth  apparently  extends  to  the 
cut  surface  anteriorly.  Upward  the  growth  can  be  traced  as  far  as 
the  internal  os.  In  the  body  of  the  uterus  the  muscle  varies  from 
2  to  2.5  cm.  in  thickness.  On  making  an  examination  through  the 
right  cornu  we  find  that  the  inner  zone  of  muscle  over  an  area  2.5  cm. 
in  diameter  presents  a  diffuse  myomatous  thickening.  There  is  an 
area  covered  by  muscle  6  mm.  in  thickness.  Exactly  the  same  con- 
dition is  noted  on  the  left  side,  except  that  the  myomatous  muscle 
extends  almost  entirely  through  the  wall.  The  uterine  walls  are 
covered,  both  anteriorly  and  posteriorly,  with  dense  adhesions. 
The  tube  on  the  right  side  is  involved  in  adhesions  and  is  the  seat  of 
a  hydrosalpinx.  On  the  left  side  we  have  a  typical  follicular 
hydrosalpinx. 

Histological  examination  was  made  of  sections 
embracing  the  uterine  cavity  and  the  anterior  and  posterior  walls. 

Even  with  the  dissecting  microscope  a  most  complete  idea  of  the 
condition  is  obtainable.  The  surface  epithelium  is  intact,  the  glands 
are  normal,  and  the  mucosa  is  seen  penetrating  the  muscle  in  all 
directions.  Nearly  everywhere  in  the  depth  one 
is  able  to  trace  the  continuity  of  the  islands 
of  mucosa  with  that  lining  the  uterine  cav- 
ity (Fig.  58).  In  the  depth  we  have  large  areas  of  uterine 
mucosa,  some  of  them  5  mm.  in  thickness.  Occasionally  some  of 
these  deep-seated  uterine  glands  are  dilated.  At  one  point  in  the 
depth  is  a  miniature  uterine  cavity,  9  mm.  in  length,  varying  from 
2  to  3  mm.  in  diameter.  It  is  lined  with  one  layer  of  epithelium 
which  has  taken  up  a  great  deal  of  blood  pigment.  Beneath  this  is 
a  zone  of  stroma  separating  it  from  the  muscle.  The  cavity  is  filled 
with  blood — the  remains  of  the  former  menstrual  flow.  The  inner 
layers  of  the  uterine  muscle  show  diffuse  myomatous  transformation. 

We  have  here  a  squamous-cell  carcinoma  of  the  cervix,  diffuse 
adenomyoma  of  the  anterior  and  of  the  posterior  uterine  wall,  with 
the  gland  elements  originating  from  the  mucosa. 


ASSOCIATED    SQUAMOUS-CELL    CARCINOMA    OF    CERVIX 


209 


/ 


Gyn.  No.  9971.     Path.   No. 
6150. 

S  q  u  a  in  0  u  s  -  c  ell 
c  a  r  c  i  n  0  m  a  0  f  1  h  e 
c  e  r  v  i  x  (Fig.  .V.)  : 
diffuse  a deno- 
111  y  0  m  a  of  t  h  e 
body  of  the  uter- 
u  s  . 

A.  S.,  married,  aged 
forty,  white.  Admitted 
October  8,  1902;  dis- 
charged November  12, 
1902.  Complaint:  Uter- 
ine hemorrhage  and  a 
watery  discharge.  The 
patient  has  been  married 
twenty-four  years  and 
has  had  four  children; 
the  oldest  twenty-three, 
the  youngest   seventeen. 


Fig.  59. — Squamous-cell  carcin- 
oma OFTHE  CERVIX;  DISCRETE, 
SUBPERITONEAL  AND  INTER- 
STITIAL MYOMATAJ  DIFFUSE 
ADENOMYOMA  OF  THE  POSTE- 
RIOR OTERINE  WALL.      (Natural 

size.  1 

Gyn .    No.    9971.      Gyn.- 
Pa  1I1.    X  ...    61  •">().     The  lower 
picture  represents  the  cervix  with 
a  small  cuff  of  vaginal  mucosa  sur- 
rounding it.     The   cervix   presents 
a    roughened   and   slightly  nodular 
appearance  due   to  the  carcinoma. 
From  tlic  upper  picture  we  see  that 
the  growth  has  invaded  the  cervix 
to  a  considerable  extent .     Situated  in  the  fundus  are  two  discrete  myomata.     The  posterior  wall 
shows  diffuse  myomatous  thickening  and  at  several  points,  indicated  by  ''.  discrete  myomata 
are  scattered  throughout   the  diffusely  thickened  myomatous  tissue.     Histological  examination 
shows  islands  of  mucosa  scattered  abundantly  throughout   the  diffuse  myoma. 
14 


210  ADENOMYOMA  OF  THE  UTERUS 

The  labors  were  normal.  The  patient  was  well  until  May  of  this 
year,  when  she  had  a  slight  hemorrhage  and  later  noticed  a  slight 
serous  discharge,  which  was  irritating. 

Operation  .—On  examination  of  the  cervix  so  strong 
was  the  suspicion  of  carcinoma  that  a  complete  hysterectomy  was 
done.  The  appendages  were  adherent  to  the  posterior  surface  of 
the  uterus  and  the  cervix  was  released  with  a  great  deal  of  difficulty. 
After  operation  there  was  excessive  nausea  and  fecal  vomiting  for 
several  days.  For  the  first  ten  days  the  patient's  life  hung  in  the 
balance,  but  later  on  convalescence  was  rapid.  The  highest  post- 
operative temperature  was  100°  F.,  on  the  second  day. 

Path.  No.  6150  . — The  specimen  consists  of  a  myoma- 
tous uterus  which  has  been  removed  entire.  The  myoma  devel- 
oping in  the  anterior  wall  is  4  cm.  in  diameter.  Below  this  and 
posterior  to  it  is  a  similar  one.  The  uterus  is  12  cm.  long  and  6.5 
cm.  broad.  The  anterior  lip  is  denser  than  the  posterior  and  suggests 
a  new  growth.  On  careful  examination  both  lips  are  seen  to  present 
a  finely  granular  appearance  (Fig.  59).  The  uterine  cavity  measures 
3.3  cm.  in  length.  The  posterior  uterine  wall  is 
fully  3  cm.  in  thickness  and  presents  a  fine 
diffuse  myomatous  appearance. 

On  histological  examination  the  cervix  is  found 
to  be  the  seat  of  a  squamous-cell  carcinoma.  This  has  not  been 
entirely  removed.  Sections  from  the  posterior  wall  of  the  uterus 
show  that  it  is  everywhere  infiltrated  with  irregular  islands  of 
uterine  mucosa.  The  tissue  is  made  up  of  diffuse  myomata.  In 
the  anterior  wall  there  is  a  thickening  of  the  uterine  mucosa,  but  it 
is  normal.  In  the  examination  of  mairy  sections  only  at  one  point 
is  noted  a  slight  tendency  for  the  mucosa  to  extend  into  the  depth, 
and  one  cannot  with  any  degree  of  certainty  say  that  there  is  a 
direct  continuity  with  the  glands  in  the  endometrium. 

We  are  here  dealing  with  squamous-cell  carcinoma  of  the  cervix, 
interstitial  myomata,  and  diffuse  adenomyoma  of  the  posterior  wall. 


ASSOCIATED    SQUAMOUS-CELL   CARCINOMA    OF    CERVIX  211 

C.  H.  I.  No.  511.     Path.  No.  8426. 

S  <|  u  a  in  11  iis-ccl  I  c  a  r  c  i  n  0  m  a  0  I  t  h  c  c  c  r  v  i  x  : 
diffuse  a  (1  e  n  0  in  y  (»  in  a  0  f  t  li  e  b  0  d  >'  W  i  1  h  the 
g  1  a  n  (1   elements  c  o  m  i  n  g   f  r  0  in    1  h  e   in  11  c  0  s  a  . 

E.  J.  lv.,  married,  aged  sixty,  white.  Admitted  March  21,  L905; 
died  March  24,  1905.  Complaint:  Uterine  hemorrhages  and  pain. 
(The  patient  had  a  definite  squamous-cell  carcinoma  of  the  cervix 
which  obscured  the  other  symptoms.)  The  patient  has  had  ten 
children,  the  eldest  thirty-six,  the  youngest  ten  years;  no  mis- 
carriages. In  September,  1904,  she  was  paralyzed  on  the  right  side. 
It  was  three  months  before  she  regained  complete  control  over  her 
right  hand. 

Operation  . — Complete  hysterectomy  was  performed.  The 
patient  did  well  for  the  first  day,  was  restless  on  the  second  day. 
There  was  complete  suppression  of  urine,  although  the  ureters  had 
been  carefully  dissected  out  and  had  been  found  to  be  in  no  way 
obstructed.  She  soon  became  cyanosed  and  there  was  muscle 
twitching;   she  died  on  the  second  day  after  operation. 

Path.  N  o  .  8426  . — The  specimen  consists  of  the  uterus  and 
of  a  part  of  the  vagina;  also  of  the  tubes  and  ovaries.  The  cervix 
is  the  seat  of  an  extensive  carcinoma  which  involves  the  posterior 
lip  and  a  portion  of  the  vagina.  There  are  also  some  nodules  in  the 
vagina.  Posteriorly  the  growth  apparently  extends  to  the  line  of 
incision  and  out  into  the  left  parametrium.  The  body  of  the  uterus 
looks  normal. 

On  histological  examination  the  cervix  pre- 
sents a  far  advanced  squamous-cell  carcinoma. 

The  chief  interest  is  centered  in  the  endometrium.  The  uterine 
walls  are  atrophic,  and  with  the  low  power  one  can  see  very  large 
blood-vessels  in  the  outer  layers.  These  show  beginning  oblitera- 
tive  changes.  The  muscle  of  the  uterine  wall  is  exceedingly  dense 
and  looks  myomatous.  T  h  e  e  n  d  o  in  e  t  r  i  u  in  i  s  a  t  r  0  p  hie. 
but  at  s  e  v  e  r  a  1  points  w  e  c  a  n  trace  it  e  x  t  e  n  d  - 
i  n  g  a  1  o  n  g  dist  a  n  c  e  into  the  d  e  p  t  h  .  We  have 
here  a  mild  grade  of  adenomvoma. 


212  ADENOMYOMA  OF  THE  UTERUS 

Diagnosis. — Squamous-cell  carcinoma  of  the  cervix; 
moderate  diffuse  adenomyomatous  formation  in  the  body  of  the 
uterus. 

Gyn.  No.  12,060.    Path.  No.  8602. 

Squamous-cell  carcinoma  of  the  cervix; 
diffuse  adenomyoma  of  the  body  of  the  uterus 
with  the  glands  originating  from  the  mucosa. 

L.  N.,  married,  aged  fifty-six,  white.  Admitted  April  18,  1905; 
discharged  May  21,  1905.  The  patient  has  had  four  children,  the 
youngest  fourteen  years  old.  The  menopause  occurred  two  years 
ago. 

Operation  . — Panhysterectomy.  As  the  growth  was  far 
advanced  the  operation  was  fraught  with  much  difficulty.  The 
highest  post-operative  temperature  was  101.4°  F.  The  patient 
made  a  satisfactory  recovery. 

Path.  Xo.  8602  . — The  specimen  consists  of  the  uterus, 
which  is  almost  normal  in  size,  and  of  the  appendages.  The  uterus 
with  the  enlarged  cervix  is  9  cm.  in  length,  6  cm.  in  breadth,  and  4 
cm.  in  its  antero-posterior  diameters.  Anteriorly  it  is  smooth  and 
glistening.  Posteriorly  it  is  almost  free  from  adhesions.  The  cervix 
has  been  converted  into  a  crater-like  cavity  approximately  5  cm.  in 
diameter.  The  outer  vaginal  portions  of  the  cervix  are  normal,  but 
posteriorly  and  anteriorly  it  is  wanting,  the  tissue  presenting  an 
eaten-out  wormy  appearance.  Anteriorly  the  growth  extends  almost 
to  the  cut  surface.  On  section,  macroscopically  the  growth  can  be 
traced  for  at  least  1  cm.  into  the  underlying  tissue.  The  uterine 
muscle  shows  little  or  no  thickening,  but  the  inner  layers 
are  somewhat  coarser  than  usual.  The  mucosa 
varies  from  1  to  2  mm.  in  thickness. 

Histological  examination  shows  a  typical  squa- 
mous-cell carcinoma  of  the  cervix  with  a  good  deal  of  small  round- 
cell  infiltration  along  the  margins.  The  cervical  glands  are  con- 
siderably dilated  and  the  stroma  in  the  cervical  portion  has  not  quite 
the  ordinary  appearance  and  somewhat  resembles  muscle. 


ASSOCIATED    SQUAMOUS-CELL    CARCINOMA    OF    CERVIX  213 

Sections  from  the  mucosa  show  thai  the  surface  epithelium  is  in 
places  intact;  at  many  points,  however,  it  has  been  mechanically 
removed.  The  glands  are  normal  in  size,  bul  at  other  points  are 
dilated,  and  the  cell  protoplasm  is  undergoing  disintegration.  At 
some  points  we  have  isolated  glands  penetrating  the  muscle  and 
extending  into  the  depth  in  funnel-shaped  forms.  In  ot  h  e  r 
places  t  w  0  0  r  t  h  r  e  e  g  lands  can  be  t  r  ;i  C  e  d  for 
at  least  4  mm.  i  n  t  o  the  u  n  d  e  r  1  y  i  n  g  t  issue. 
This  extension  into  the  depth  is  noted  at  several  points,  and  in  the 
underlying  muscle  are  islands  of  perfectly  normal  mucosa.  The 
muscle  surrounding  the  uterine  cavity  is  denser  than  usual  and  is 
undergoing  a  diffuse  myomatous  transformation.  The  muscle  in 
the  outlying  portion  is  fairly  normal.  We  have  here  an  adeno- 
myoma  in  which  the  gland  elements  are  derived  from  the  uterine 
mucosa. 

Diagnosis  . — Primary  squamous-cell  carcinoma  of  the  cer- 
vix; diffuse  adenomyoma  of  the  body  of  the  uterus. 

Gyn.  No.  12,304.    Path  No.  8890. 

Squamous-cell  carcinoma  of  the  cervix. 
The  chief  interest  lies  in  the  adenomyoma 
of    the    body. 

L.  S.,  aged  fifty,  white.  Operation,  August  IS,  1905.  Pan- 
hysterectomy. 

Sections  from  the  endometrium  show  that  t  h  e  m  u  c  o  s  a  c  a  n 
be  in  places  traced  for  at  1  e  a  s  t  3  or  4  mm. 
into  the  u  n  d  e  r  1  y  i  n  12;  m  u  s  c  1  e  .  It  shows  a  typical 
myomatous  picture.  We  have  here  a  diffuse  adenomyoma  with 
carcinoma  of  the  cervix. 

Gyn.  No.  3126.     Path.  No.  493. 
S  q  u  a  m  o  u  s  -  c  e  1  1   c  a  r  c  i  n  0  m  a   of   t  h  e   c  e  r  v  i  x     Fig. 
60).      A  d  e  n  0  m  y  o  m  a   0  f   the   bod  y   0  f   t  h  e   u  t  e  r  u  s  . 

L.  E.  II.,  white,  aged  fifty-six,  a  widow.     Admitted  October  21. 
L894;     discharged   November  25,    1894.     The  patient   entered  the 


214  ADENOMYOMA  OF  THE  UTERUS 

hospital  complaining  of  pain  in  the  rectum  and  lower  part  of  the  back. 
She  had  had  some  hemorrhage.  Two  paternal  aunts  had  died  of 
phthisis,  and  her  mother  of  cancer  of  the  uterus  at  forty-nine  years 
of  age.  Her  paternal  grandmother  was  also  supposed  to  have  died 
of  cancer  of  the  uterus. 

Menstrual  History  . — The  periods  commenced  at  six- 
teen; they  were  always  regular,  but  painful  during  the  first  few 
years.  She  suffered  from  membranous  dysmenorrhcea.  For  the 
last  ten  years  there  has  been  an  offensive  odor  at  the  menstrual  period. 
The  menopause  occurred  at  fifty-three.  She  had  had  several  chil- 
dren. 

Present  Illness  . — For  five  or  six  years  before  the 
menopause,  which  occurred  three  years  ago,  the  patient  suffered 
with  irregular  and  severe  hemorrhages  from  the  uterus.  From  the 
time  of  the  menopause  no  hemorrhages  occurred,  but  the  patient 
complained  of  nervousness.  In  July  of  this  year  she  noticed  a 
yellowish  vaginal  discharge.  In  August  she  complained  of  pain  in 
the  lower  abdomen  and  of  some  swelling  in  the  legs. 

In  July  and  August  the  desire  to  urinate  was  constant.  These 
symptoms  have  subsided  since  then.  The  bowels  are  markedly 
constipated  and  defecation  is  accompanied  by  hemorrhage.  There 
is,  however,  no  tingeing  of  the  stools  with  blood. 

The  patient  is  very  anaemic  and  nervous,  but  there  is  no  marked 
emaciation. 

Operation  . — The  carcinoma  of  the  cervix  was  curetted 
away  as  far  as  possible  with  the  finger.  After  thorough  cleansing 
of  the  uterus  the  vagina  was  incised,  an  area  around  the  margin  of 
about  1  cm.  of  normal  mucosa  being  loosened  up  with  the  cervix. 
An  abscess  between  the  uterus  and  rectum  was  then  opened  and 
about  2  c.c.  of  creamy  pus  escaped.  The  vaginal  edges  were  brought 
together  so  that  the  diseased  area  of  the  cervix  was  completely  walled 
off.  The  abdomen  was  then  opened  and  the  uterus  removed  from 
above.  Considerable  difficulty  was  experienced,  however,  on  ac- 
count of  the  extension  of  the  growth  to  the  broad  ligament.  The 
patient  made  a  good  recovery  and  was  discharged  on  November 


ASSOCIATED   SQUAMOUS-CELL    CARCINOMA    OF    CERVIX 


215 


25th.  The  nervous  symptoms  were,  however,  prominent.  Re- 
appearance of  the  growth  was  noted  and  the  patienl  died  sixty  days 
after  operation,  apparently  of  exhaustion. 

Gyn.-Path.     No.    493.     The  specimen    consists  of   the 


■^S^SBBA 


m^y 


A  8 

Fig.    60. — Commencing    diffuse    adenomyoma    of    the    body   of  the    uterus   associated 

"WITH    ADVANCED    SQUAMOUS-CELL    CARCINOMA    OF   THE    CERVIX.       t  ,''„   natural  size.) 

Gyn.-Path.    No.    493.      A,   The  lower  part  of  the  cervix  and  surrounding  portions 

of  the  vaginal  vault  arc  replaced  by  a  new  growth  having  a  shaggy  surface  due  to  myriads  of  finger- 
like outgrowths.  Laterally  this  growth  extends  practically  to  the  broad  ligament  attachment: 
upward  its  confines  are  indicated  by  the  letters  a.  a.  The  upper  part  of  the  cervix  and  body 
seem  little  altered.  At  b  is  a  small  polyp.  The  mucosa  in  the  upper  part  of  the  cervix  and  in 
the  body  is  very  thin  hut  smooth.  />'.  a  longitudinal  section  of  .t.  The  extent  of  tin1  growth  in 
the  posterior  wall  is  clearly  outlined  at  a.  The  cystic  cervical  polyp  is  seen  at  c.  The  posterior 
wall  is  made  up  of  two  distinct  portions,  an  outer  consisting  of  normal  muscle  and  an  inner  pre- 
senting a  diffuse  myomatous  appearance.  This  coarse  tissue  extends  directly  to  the  mucosa. 
At  '/  is  a  small  discrete  myomatous  nodule.  From  the  text  it  will  lie  noted  that  the  uterine 
walls  show  a  commencing  myomatous  transformation  and  that  the  glands  in  many  places  pene- 
trate the  muscle  for  a  distance  of  0  mm. 


uterus  with  its  appendages  intact.  The  uterus  measures  8  by  6 
by  3  cm.  and  both  anteriorly  and  posteriorly  is  smooth  and  glisten- 
ing.    Occupying  the  outer  portion  of  the  cervix,  both  anteriorly 

and  posteriorly,  is  a  worm-eaten  and  in  part  papillary-like  surface 
(Fig.  60).     In  the  latter  portion  the  little  elevations  are   found  to 


216  ADENOMYOMA  OF  THE  UTERUS 

consist  of  small  finger-like  or  knob-shaped  processes,  some  of  which 
apparently  branch.  Anteriorly  the  growth  extends  out  to  the  vagina, 
while  posteriorly  it  involves  the  vault  for  at  least  1.5  cm.  On  section 
it  is  found  that  only  the  outer  portion  of  the  cervix  is  implicated  and 
that  the  cervical  mucosa  for  a  distance  of  2.5  cm.  is  still  intact. 
Several  of  the  cervical  glands  are  dilated,  and  projecting  into  the 
canal  is  a  small  polyp.  The  uterine  cavity  is  3  cm.  long.  Its  mu- 
cosa, which  appears  to  be  less  than  a  millimetre  in  thickness,  is  smooth 
and  glistening.  Situated  on  the  left  side  of  the  cavity  is  a  pale 
bluish-white  polyp  1  cm.  long,  1.2  cm.  broad,  4  mm.  thick.  The 
tubes  and  ovaries  present  their  usual  appearance. 

Histological  Examination  . — The  worm-eaten  cer- 
vix shows  considerable  necrosis  of  its  surface.  The  underlying 
tissue  is  everywhere  infiltrated  by  masses  of  cells  having  a  finger-like 
or  branching  arrangement.  Some  of  these  have  been  cut  across  and 
appear  as  circular  nests.  Scattered  throughout  the  alveoli  are 
numerous  areas  in  which  the  cell  protoplasm  stains  intensely  with 
eosin.  The  concentric  arrangement  of  the  cells  is  suggestive  of 
epithelial  pearls.  The  new  growth  appears  to  extend  nearly  to  the 
margin  of  the  incision.  Whether  or  not  it  has  been  entirely  removed, 
it  is  impossible  to  say.  The  tissue  surrounding  the  alveoli  shows 
marked  small  round-cell  infiltration  along  the  advancing  margin  of 
the  growth. 

The  cervical  glands,  just  within  the  external  os,  are  normal,  but 
as  one  approaches  the  internal  os  many  of  them  are  dilated.  The 
uterine  mucosa  near  the  internal  os  and  also  that  throughout  the 
cavity  shows  considerable  dilatation  of  its  glands  and  scattered 
throughout  the  stroma  are  numerous  small  round  cells.  Pene- 
trating the  muscle  in  many  places  to  a  depth 
of  9  mm.  are  bunches  of  very  small  glands,  which 
are  separated  from  each  other  and  also  from  the  muscle  by  the  usual 
amount  of  stroma.  They  are  abnormal  dippings-down  of  the  mu- 
cosa, which  do  not,  however,  show  the  least  sign  of  malignancy. 
The  uterine  wall  shows  some  hyaline  degeneration.  The  muscle 
tends  to  become  myomatous  and  in  one  place  contains  a  myoma  4 


ASSOCIATED    SQUAMOUS-CELL    CARCINOMA    OF   CERVIX  217 

mm.    in    diameter.     The    uterine    polyp    consists    of    mucosa    and 
a  few  of   its  glands   are  dilated.     The   appendages  are  practically 

normal. 

D  i  a  g  n  o  s  i  s  . — Squamous-cell  carcinoma  of  the  cervix ;  ex- 
tension of  the  uterine  glands  into  the  muscular  walls,  which  show 
a  tendency  to  become  myomatous;  small  interstitial  myoma;  nor- 
mal appendages. 


CHAPTER  XVIII 

ADENOCARCINOMA  AND  ADENOMYOMA  OCCURRING  INDEPENDENTLY 
IN  THE  BODY  OF  THE  SAME  UTERUS 

The  following  case  is  interesting  on  account  of  the  fact  that  an 
adenocarcinoma  of  the  body  of  the  uterus  and  a  small  but  typical 
subperitoneal  adenomyoma  are  associated  in  the  same  uterus.  Of 
course,  the  one  is  in  no  way  dependent  on  the  other. 

Gyn.  No.  5782.     Path.  No.  2084. 

Adenocarcinoma  of  the  body  of  the  ut- 
erus (Fig.  61);  small  myoma  in  the  anterior 
wall;  small  adenomyoma  in  the  posterior 
wall;    hysterectomy. 

M.  K.,  aged  fifty-six,  admitted  January  12,  1898,  complaining 
of  pain  in  the  lower  abdomen.  The  menses  were  irregular,  oc- 
curring at  intervals  of  from  two  to  six  weeks.  They  were  very 
painful  and  lasted  from  three  to  seven  days.  They  ceased  four 
years  ago.  About  a  year  and  a  half  ago  a  bloody  discharge  was 
noticed  which  at  times  was  clotted.  During  the  last  six  months 
it  has  been  frequent,  but  at  no  time  has  it  been  offensive.  The 
patient  has  been  married  twenty-one  years.  She  has  had  one 
child  and  no  miscarriages.  She  has  never  been  strong,  and  during 
the  past  year  has  had  severe  pain  in  the  lower  abdomen  extending 
down  the  legs.  At  present  the  bowels  are  constipated.  On  Jan- 
uary 12th  the  cervix  was  dilated  and  a  small  amount  of  tissue  was 
removed  for  examination.  The  uterus  was  slightly  enlarged  but 
freely  movable.  Two  nodules  could  be  seen  on  the  posterior  sur- 
face. 

Gyn. -Path.  No.  2075  . — The  specimen  consists  of  a  con- 
siderable amount  of  curettings.  The  tissue  is  composed  of  small 
pieces  which  do  not  present  the  smooth  glistening  surface  of  normal 

218 


ADENOCARCINOMA   AND   ADENOMYOMA    1  \   THE  SAME   I  TER1  -     219 


mucosa.  They  are  finely  gi 
out-growths.  ( )n  histological 
examination  adenocarcinoma 
of  the  body  of  the  uterus  was 
found  and  hysterectomy  was 
advised.  The  uterus  was  re- 
moved in  the  usual  way.  The 
patient  madeagood  recovery 
and  was  discharged  February 
15,  1898. 

Gyn.-Path.  N  o  . 
2  0  8  4  . — The  specimen  con- 
sists of  the  uterus  with  the 
appendages.  The  uterus  is 
8  cm.  in  length,  5.5  cm.  in 
breadth,  and  5  cm.  in  its  an- 
teroposterior diameter.  Its 
surface  is  deep  red  in  color 
and  free  from  adhesions,  but 
projecting  from  the  posterior 
portion  is  a  small,  firm  nodule 
1.2  cm.  in  diameter  (Fig.  61). 
The  outer  surface  of  this  no- 
dule is  covered  with  a  calcar- 
eous plate  2  mm.  in  thickness. 
On  section  the  growth  is  found 
to  be  continuous  with  the 
uterine  muscle,  with  which  it 
is  intimately  associated,  the 
sharp  line  of  demarcation  so 
characteristic  ofmyomata  be- 
ing wanting.  The  calcareous 
deposit  has  extended  into  the 
nodule  at  one  point.  The  c 
mucosa  is  finely  granular  and 


ly   granular  or  .-how  minute,  papillary-like 


Adeno  -carcinoma. 


Adeno- 
•myoma. 


-  Mvci 


Fig.  <n. — Adenocari  inoma  of  the  body  of  the 

UTERUS  ASSOCIATED   WITH   A   -MALI.    SUBPERI- 
TONEAL ADENOMYOMA.        Natural  -ize. ) 

Gyn.-Path.  No.    20  84.    The  uterus 

is  of  normal  size.  The  left  half  appears  in  the 
figure.  Attached  to  the  posterior  surface  near  the 
fundus  is  a  small  subperitoneal  myoma,  which  on 
histological  examination  is  found  to  contain  mu- 
cosa resembling  that  of  the  uterus.  In  the  middle 
of  the  anterior  wall  is  a  small  interstitial  myoma; 
the  cervix  is  intact.  The  mucosa  in  the  lower 
part  of  the  cervical  canal  is  normal,  but  that  of 
the  body  is  replace!  by  a  new  growth.  The  inner 
surface  presents  an  eaten-out  appearance  due  to 
the  finger-like  growths.  The  growth  itself  is  light 
in  color  and  appears  to  be  friable.  It  doe-  not 
seem  to  penetrate  the  uterine  walls  very  far.  but 
as  the  subsequent  history  showed  the  case  was  one 

of  the   most  malignant  we  have   encountered.      It 

i-  lather  interesting  to  find  a  myoma,  an  adeno- 
myoma  and  an  adenocarcinoma  of  the  body  of 
the  uterus  in  the  same  patient. 

ervical  canal  is  3  cm.  in  length.     Its 

slightly  injected.     The  uterine  cavity 


220  ADENOMYOMA  OF  THE  UTERUS 

is  5  cm.  long  and  4  cm.  in  breadth  at  the  fundus.  The  mucosa  in 
the  lower  portion  of  the  cavity  is  roughened  and  granular.  On 
passing  further  upward  it  is  found  to  be  thicker  and  more  furrowed. 
The  upper  half  of  the  cavity  is  occupied  by  a  new  growth  consisting 
of  papillary  masses  varying  from  1  to  6  mm.  in  size.  These  tree- 
like growths  consist  of  delicate  papillae  which  often  show  secondary 
branching.  Some  of  the  papillae  are  glistening,  some  are  translucent; 
others  are  yellowish  and  opaque,  while  not  a  few  are  deeply  injected. 
The  growth  has  extended  for  8  to  10  mm.  into  the  uterine  muscle. 
The  deeper  portions  consist  of  a  fibrillated  waxy  material,  which 
is  sharply  differentiated  from  the  surrounding  muscle.  The  growth 
penetrates  the  muscle  more  deeply  on  the  left  side.  Downward 
it  reaches  to  within  1  cm.  of  the  internal  os. 

The  appendages  are  senile,  but  present  nothing  of  importance. 

Histological  Examination  . — The  vaginal  portion 
of  the  cervix  is  practically  normal.  The  folds  of  the  mucosa  lining 
the  cervical  canal  present  the  usual  appearance.  The  surface  epithe- 
lium is  to  a  great  extent  intact  and  the  underlying  glands  are  normal. 
Sections  from  the  body  of  the  uterus  show  that  the  greater  part  of 
its  cavity  is  occupied  by  a  neoplasm.  Along  the  advancing  margin 
this  appears  in  the  form  of  irregularly  branching  outgrowths,  con- 
sisting of  delicate  stems  of  stroma  covered  by  one  or  more  layers 
of  cylindrical  epithelium.  On  passing  toward  the  older  portions  of 
the  growth  this  papillary -like  arrangement  becomes  more  complex. 
In  the  deeper  portions  the  glandular  arrangement  is  more  in  evidence, 
and  along  the  advancing  margin  where  the  growth  has  penetrated 
the  muscle,  large  bunches  of  glands  are  seen.  The  gland-like  ar- 
rangement in  many  places  is  perfectly  preserved  and  the  epithelial 
cells  are  remarkably  uniform  in  size.  In  some  places  the  stroma  is 
fairly  abundant,  but  at  other  points  it  is  only  just  sufficient  to  sup- 
port the  delicate  blood-vessels.  The  preservation  of  the  glands, 
which  show  practically  no  coagulation  necrosis,  is  rather  remarkable, 
and  is  more  probably  due  to  their  slight  deviation  from  the  normal 
than  to  any  increase  in  blood-supply,  since  the  latter  is  by  no  means 


ADENOCARCINOMA   AND   ADENOMYOMA    l\   THE  SAME    UTERI  -     221 

abundant.     Along  the  advancing  margin  of  the  growth  the  muscle 

shows  small  round-cell  infiltration. 

The  small  nodule  situated  on  the  posterior  uterine  wall  consists 
of  non-striped  muscle  fibres  cut  in  various  directions.  The  blood- 
vessels are  few  in  number  and  frequently  show  obliteration.  At 
a  few  points  2  or  3  mm.  beneath  the  peritoneal  covering  are  deeply 
staining  areas,  at  first  sight  suggesting  small  round-cell  infiltration, 
were  it  not  for  the  fact  that  they  are  too  sharply  circumscribed  and 
that  with  the  higher  powers  it  is  impossible  to  distinguish  them  from 
the  stroma  cells  of  the  uterine  mucosa.  Some  of  these  areas  contain 
glands  irregular  or  elongate  in  form  and  lined  with  one  layer  of  low 
cylindrical  epithelium  on  which  cilia  can  sometimes  be  demonstrated. 
Some  of  the  gland  cavities  contain  desquamated  epithelium;  others 
enclose  a  varying  amount  of  blood.  The  nodule  is  a  myoma.  The 
glands  and  their  surrounding  stroma  resemble  more  or  less  the  uter- 
ine mucosa.  We  are  dealing  with  a  small  sub- 
peritoneal adenomyoma.  Sections  from  the  tubes 
show  nothing  abnormal.  Both  ovaries  contain  a  few  small  gland- 
like spaces,  but  are  otherwise  normal. 

Diagnosis  . — Adenocarcinoma  of  the  body  of  the  uterus, 
associated  with  a  subperitoneal  adenomyoma  and  an  interstitial 
mvoma. 


CHAPTER  XIX 

ADENOCARCINOMA  OF  THE  BODY  OF  THE  UTERUS  DEVELOPING 
FROM  AN  ADENOMYOMA 

From  our  consideration  of  adenomyomata  of  the  uterus,  it  is 
seen  that  the  gland  elements  are  practically  normal  uterine  glands 
in  both  their  histological  and  physiological  aspects.  From  normal 
uterine  mucosa  we  often  have  developing  an  adenocarcinoma.  Con- 
sequently we  should  not  be  surprised  if  an  adenocarcinoma  were 
sometimes  detected  in  an  adenomyoma.  Von  Recklinghausen  in 
his  entire  series  of  adenomyomata  found  only  two  cases  in  which 
he  thought  there  was  a  carcinomatous  change.  Meyer  also  had  a 
suspicious  case,  but  from  his  description  we  would  hardly  venture 
a  positive  diagnosis  of  malignancy.  In  Gyn.-Path.  Xo.  4656,  an 
instance  of  carcinoma  of  the  body  of  the  uterus,  we  noted  several 
dark  areas  deep  in  the  muscle.  They  consisted  of  typical  islands 
of  uterine  glands  surrounded  by  the  stroma  of  the  mucosa.  Some 
of  the  glands  were  dilated,  forming  cyst-like  cavities.  In  one  of 
these  cavities  (Fig.  62),  lined  by  a  single  layer  of  cylindrical  epithe- 
lium and  separated  from  the  muscle  by  a  definite  stroma,  the  epi- 
thelium had  proliferated,  forming  new  glands  and  papillary  out- 
growths consisting  almost  entirely  of  solid  masses  of  cancer  cells. 
This  case  is  undoubtedly  one  of  adenocarcinoma  developing  in  part 
from  a  cystic  gland  situated  in  the  adenomyoma. 

In  Sanitarium  No.  1852  we  found  a  similar  condition.  The 
body  of  the  uterus  was  the  seat  of  a  typical  adenocarcinoma  and 
deep  in  the  muscle  areas  of  adenomyoma  were  found.  At  one  point 
the  carcinoma  was  seen  developing  from  one  of  the  glands  in  the 
adenomyoma.  In  this  case  the  histological  picture  also  strongly 
suggested  the  independent  development  of  sarcoma  of  the  body  of 
the  uterus. 


ADENOCARCINOMA    DEVELOPING    PROM    A.DENOMYOMA  223 

CASES   ILLUSTRATING    THE    DEVELOPMENT    OF    ADENOCARCINOMA    OF    THE 
BODY  OF  THE  UTERUS  FROM  ADENOMYOMA 

Gyn.  No.  8438.    Path.  No.  4656. 

Adeno  c  a  r  <•  i  n  0  m  a  0  f  the  body  of  the  uterus 
developing,  in  part  at  least,  from  the  glands 
0  f   a  n    a  d  e  n  0  in  y  0  m  a    (Fig.    62). 

M.  S.,  married,  aged  fifty-six,  white.  Admitted  January  9; 
discharged  February  9,  1901.  The  patient  entered  complaining  of 
uterine  hemorrhages.  The  menses  commenced  at  seventeen  and 
were  not  painful.  The  menopause  occurred  at  fifty-three.  The 
patient  has  had  five  children,  the  eldest  thirty-three  years  of  age. 

One  year  after  the  menopause,  i.  e.,  two  years  airo,  the  patient 
noticed  a  slight  uterine  discharge,  usually  blood  tinged.  This  has 
been  a  little  more  profuse  of  late  and  has  contained  some  blood. 
She  has  neither  pain  nor  discomfort  and  has  lost  no  weight.  The 
only  symptom  has  been  the  uterine  bleeding. 

January  19,  1905:  Vaginal  hysterectomy.  The  patient  made  a 
satisfactory  recovery. 

Gyn. -Path.  X  o  .  4  6  5  6  . — The  specimen  consists  of  the 
uterus,  which  is  little,  if  at  all,  enlarged,  measuring  8  by  6  by  4 
cm.  The  outer  surface  is  smooth  and  the  vaginal  portion  of  the 
cervix  presents  the  usual  appearance.  The  cervical  mucosa  is  in- 
jected but  normal.  In  the  uterine  cavity  nearly  all  trace  of  the 
normal  mucosa  has  disappeared  and  we  have  fine  finger-like 
processes  or  small  polypoid  masses,  some  reach- 
ing 1  cm.  in  length,  springing  from  the  surface.  The  deeper  portions 
of  this  growth  have  invaded  the  muscle  in  the  vicinity  of  the  cornu 
for  a  distance  of  from  5  to  7  mm.  The  uterine  walls  are  of  the  normal 
thickness,  but  at  some  points  the  tissue  is  coarser  than  usual  and  is 
somewhat  suggestive  of  a  diffuse  myoma. 

Histological  Ex  a  m  i  n  a  t  i  o  n  .  The  cervical  mucosa 
is  perfectly  normal.  Near  the  internal  os  the  epithelial  Lining  of  the 
glands  is  altered.  Some  of  the  cells  are  quite  regular  and  uniform. 
Others  are  swollen,  have  ught-staining  nuclei,  and  arc  several  layers 
thick.     High   in   the   cavity   the  glands  have  proliferated   and   are 


224 


ADENOMYOMA    OF    THE    UTERUS 


Fig.  62. — Adenocarcinoma  developing  from  a  dilated  gland  in  an  adenomyoma  of  the 

uterus.     (45  diameters.) 

Gyn.-Path.  No.  46  5  6.  Occupying  the  centre  of  the  field  is  a  large  cystic  space 
lined  with  one  layer  of  cylindrical  epithelium  (a)  and  separated  from  the  surrounding  myomatous 
muscle  (c)  by  a  faint  zone  of  characteristic  stroma  (b).  In  the  upper  part  of  the  field  numerous 
glands  are  seen  opening  into  the  large  cavity.  These  glands  are  also  lined  with  cylindrical  epi- 
thelium. Projecting  into  the  cavity  are  the  four  large  folds  d,  d' ,  d"  and  d'".  These  new  folds 
have  a  stroma  very  rich  in  small  round  cells  and  are  surrounded  by  many  layers  of  epithelial 
cells.  At  points  e,  e,  e  the  gland  epithelium  is  seen  to  become  swollen  and  greatly  thickened  and 
this  thickened  epithelium  is  directly  continuous  with  that  covering  the  folds.  As  is  clearly  evi- 
dent, the  growth  is  an  adenocarcinoma.  In  this  case  the  carcinoma  was  seen  developing  from 
other  similar  areas  as  well  as  from  the  mucosa  lining  the  uterine  cavity. 


ADENOCARCINOMA    DEVELOPING    FROM    ADENOMYOMA  225 

invading  the  muscle.  The  gland  type,  as  u  rule,  is  well  preserved, 
but  in  some  places  the  epithelium  has  so  proliferated  thai  the  gland 
cavities  arc  obliterated.     Deep  down  in  the  muscle  are  groups  of 

carcinomatous  glands,  which  in  places  extend  to  within  1  cm.  of 
the  peritoneal  surface.  In  some  places  there  is  a  moderate  infiltra- 
tion with  polymorphonuclear  leucocytes.  In  some  portion-  of  the 
uterus  the  muscle  fibres  stain  more  deeply  than  usual  and  show  a 
tendency  to  become  myomatous.  Here  the  tissue  suggests  a  diffuse 
myoma.  Scattered  throughout  it  are  isolated  islands  of  uterine 
mucosa  consisting  of  the  characteristic  glands  with  their  surround- 
ing stroma.  At  several  points  these  glands  are 
dilated,  and  in  at  least  t  w  o  places  the  gland 
epithelium  has  proliferated,  forming  n  e  w 
g  1  a  n  d  s  of  a  n  u  n  d  o  u  b  ted  car  c  inomatous  t  y  p  e  . 
Fig.  62  illustrates  a  carcinoma  developing  from  one  of  these  cystic 
and  dilated  uterine  glands.  It  shows  conclusively  that  carcinoma 
may  develop  from  the  gland  elements  of  an  adenomyoma.  This, 
however,  is  nothing  more  than  we  might  expect,  since  the  gland 
elements  of  adenomyomata  are,  as  a  rule,  nothing  more  than  normal 
uterine  glands  which  have  grown  into  the  muscle. 

H.  A.  K.  Sanitarium  No.  1852.     Path.  No.  8347. 

A  d  e  11  o  c  a  r  c  i  n  0  m  a  0  f  the  body  of  the  uterus; 
diffuse  a  d  e  n  o  m  y  o  m  a  wT  i  t  h  t  h  e  g  1  a  n  d  s  1)  e  c  o  m  - 
i  n  g  carcinomatous.  Independent  s  a  r  c  o  m  a  0 f 
t  h e   b 0  d  y   of   t  h  e   u terns. 

B.  H.  C,  aged  fifty-four,  white,  married.  Admitted  March  31, 
1905;  discharged  April  21,  1905  Operation:  Panhysterectomy, 
colostomy  and  removal  of  vaginal  implantation. 

The  patient  has  been  married  twenty-seven  years  and  has  had 
four  children  but  no  miscarriages.  The  menopause  occurred  four 
years  ago.  For  three  months  there  has  been  a  constant  leucorrhoea 
with  a  bloody  vaginal  discharge. 

Operation,  March  8th.  Panhysterectomy.  The  patient 
did    not    improve    well    after   operation,    and    finally   on   the   fifth 

15 


226  ADENOMYOMA  OF  THE  UTERUS 

day  it  was  found  necessary  to  bring  out  a  loop  of  small  intestine. 
This  was  fastened  to  the  abdominal  wall  and  was  opened  with  a 
cautery.  At  a  later  date  the  patient  became  insane.  She  had  a 
return  of  the  growth  in  the  vaginal  wall.  For  this  radium  was  used. 
Later  she  went  to  Dr.  John  McCoy,  of  Paterson,  N.  J.,  for  x-ray 
treatment. 

In  May,  1905,  her  condition  was  much  worse,  and  her  physician 
removed  a  vaginal  mass  under  cocaine.  At  the  time  he  made  a  note 
that  there  was  a  tremendous  amount  of  infiltration  of  the  tissue 
between  the  vagina  and  rectum.  Pathological  examination  of  the 
vaginal  specimen  showed  it  to  be  a  typical  sarcoma. 

Path.  No.  8347  . — The  uterus  is  10  cm.  long,  8  cm.  broad, 
and  6  cm.  in  its  antero-posterior  diameters.  The  cervix  looks  nor- 
mal. The  uterine  walls  vary  from  2  to  4  cm.  in  thickness.  The 
increased  thickening  in  the  posterior  wall  is  due  to  a  new  growth 
which  projects  into  the  cavity.  The  superficial  half  of  this  is  blu- 
ish-black in  color.  The  outlying  portions  are  white  and  somewhat 
porous  in  appearance  and  sharply  differentiated  from  the  normal 
outer  muscular  covering.  The  appendages  on  both  sides  appear  to 
be  unaltered. 

Histological  Examination  . — Sections  from  the 
cervix  show  that  the  surface  epithelium  is  the  seat  of  chronic  infil- 
tration, there  being  a  marked  round-cell  infiltration,  also  polymor- 
phonuclear leucocytes,  and  the  underlying  stroma  is  exceedingly 
vascular.  Sections  from  the  uterine  mucosa  show  that  there  is  in 
places  loss  of  surface  epithelium.     In  other  places  it  is  intact. 

The  endometrium  in  the  lower  part  of  the  body  shows  consider- 
able hemorrhage,  evidently  the  result  of  curettage.  The  stroma  is 
infiltrated  with  small  round  cells  to  a  limited  extent  and  the  glands 
are  seen  projecting  into  the  underlying  muscle.  Sections  from  the 
upper  part  of  the  body,  where  the  growth  is  present,  show  that  the 
surface  of  the  growth  is  almost  entirely  necrotic  and  that  this  ne- 
crotic material  contains  quantities  of  polymorphonuclear  leucocytes 
and  blood.  At  other  points  in  the  necrotic  material  we  have  longi- 
tudinal sections  of  blood-vessels  surrounded  by  many  layers  of  cells 


ADEXOCARCIXOMA    DEVELOPING    PROM    ADENOMYOMA  22/ 

having  oval,  deeply  staining  nuclei.  Such  areas  suggesl  very  much 
an  angiosarcoma.  In  other  portions  of  the  growth  the  cells  are 
closely  packed  together;  nevertheless  with  the  low  power  ii  i-  possible 
to  make  out  an  indefinite  glandular  arrangement.     In  other  words, 

down  near  the  muscle  we  have  a  typical  adenocarcinoma  of  the  type 
so  frequently  found  in  the  body,  the  skein-like  arrangement  of  the 
glands  and  the  papillary  outgrowths,  and  all  of  these  covered  by 
one  and  sometimes  several  layers  of  epithelium.  There  are  also 
numerous  minute  glands.  The  line  of  junction  between  the  portion 
of  the  growth  that  looks  sarcomatous  and  that  which  is  distinctly 
cancerous  is  sharply  outlined.  Sections  from  other  portions  of  the 
growth  leave  little  doubt  that  we  are  dealing  with  a  sarcoma,  there 
being  large  fields  with  cells  uniform  in  size  and  having  very  little 
stroma,  just  sufficient  to  cany  the  blood-vessels.  Numerous  nuclear 
figures  are  found  scattered  through  this  tissue. 

Another  most  interesting  point  in  this  connection  is  the  presence 
of  islands  of  normal  glands  in  the  depth.  Some  of  these  have  sur- 
rounding stroma  and  present  the  typical  appearance  of  adenomy- 
oma.  Islands  of  mucosa  are  surrounded  by  myomatous  tissue,  and 
in  one  of  these  islands  we  h  a  v  e  an  adenocar- 
cinoma developing  directly  fro  m  the  m  u  c  o s a 
of  one  of  the  normal  glands.  One  is  able  to 
t  r  ace  the  direct  continuity  from  the  e  p  i  t  h  e  - 
1  i  u  m  i  n  s  u  c  h  an  island  into  the  c  a  r  c  i  n  o  m  a  - 
tous  tissue.  The  muscle  external  to  the  point  of  growth 
shows  a  good  deal  of  small  round-cell  infiltration. 

We  have  here  a  subacute  inflammation  of  the  cervix,  an  adeno- 
carcinoma of  the  body  of  the  uterus,  and  an  adenomyoma  of  the 
body  of  the  uterus.  To  a  certain  extent  the  adenocarcinoma  is 
derived  directly  from  islands  of  normal  mucosa  in  the  adenomyoma. 
but  in  part  evidently  from  the  uterine  mucosa  lining  the  cavity. 
There  is  an  apparently  independent  round-cell  sarcoma  in  the  body 
of  the  uterus.  Fortunately  we  are  able  to  clinch  the  diagnosis 
absolutely,  as  the  metastases  which  occurred  subsequent  to  removal 
of  the  uterus  showed  typical  sarcoma. 


CHAPTER  XX 

A  MULTIPLICITY  OF  PATHOLOGICAL  CHANGES  IN  THE  PELVIS 

(a)  Subperitoneal  myoma. 

(b)  Adenomyoma. 

(c)  Primary  adenocarcinoma  of  the  body  of  the  uterus. 

(d)  Pyosalpinx. 

(e)  Primary  adenocarcinoma  of  the  ovary. 

^Prunary    adeno  -  card  no  ma. 

\.\deno  -  myo  ma. 


Fig.  63. — Myoma,  adenomyoma  and  primary  adenocarcinoma  of  the  body  of  the  uterus; 

PYOSALPINX    AND    PRIMARY   ADENOCARCINOMA    OF    THE    OVARY.       (f  natural  Size.) 

Specimen  sent  by  Dr.  Joseph  Price,  of  Philadelphia.  Path.  X  o  .  9312.  Occupying 
the  body  of  the  uterus  is  an  adenocarcinoma.  Isolated  carcinomatous  nodules  are  scattered 
throughout  the  muscular  walls  and  at  one  point  have  nearly  reached  the  peritoneal  surface.  On 
one  side  is  a  discrete  myoma.  On  the  other  near  the  uterine  horn  a  diffuse  adenomyoma,  which 
on  histological  examination  presented  the  typical  appearance.  The  tube  is  thickened  in  its  outer 
portion  and  was  filled  with  pus.  The  ovary  has  been  converted  into  a  porous  growth,  partly 
cystic  and  divided  off  into  smaller  areas  by  trabecule.  This  carcinomatous  growth  was  of  a  totally 
different  pattern  to  that  occupying  the  uterus. 

About  two  years  ago  I  received  a  rather  unpromising-looking 
specimen  from  my  friend,  Dr.  Joseph  Price,  of  Philadelphia.  On 
careful  examination,  however,  it  was  evident  that  it  was  a  most 
unusual  one. 

228 


MULTIPLE    PATHOLOGICAL   CHANGES    l\    PELVIS  229 

From  Fig.  <»:;  we  sec  thai  the  body  of  the  uterus  is  extensively 
involved  in  an  adenocarcinoma.  <  >n  one  side  is  a  discrete  myoma, 
while  on  the  opposite  side  is  an  adenomyoma.  ( )ne  tube  is  markedly 
distended  with  pus  and  has  been  densely  adherent,  as  is  indicated 
by  adhesions.  One  ovary  is  much  enlarged  and  occupied  by  a  new 
growth. 

Histological  examination  showed  that  the  growth  was  a  primary 
adenocarcinoma  of  a  totally  different  type  from  that  occupying  the 
uterus.  There  were  in  this  pelvis  five  distinctly  independent  patho- 
logical processes. 

We  often  make  a  very  positive  diagnosis  before  operation,  only 
to  find,  when  the  abdomen  is  opened,  a  condition  totally  different 
from  that  we  had  expected.  Xo  surgeon  could  possibly  have  given 
an  accurate  diagnosis  in  such  a  case  as  this.  From  the  contour  one 
might  readily  have  diagnosed  a  multinodular  and  adherent  my- 
omatous uterus.  The  carcinoma  could,  of  course,  have  been  readily 
recognized  upon  examination  of  scrapings  from  the  body. 


CHAPTER  XXI 

DIFFUSE  MYOMATOUS  THICKENING  OF  THE  UTERUS  BUT  NO 
GLANDULAR  INVASION 

Whenever  the  uterus  is  the  seat  of  diffuse  myomatous  thicken- 
ing, adenomyoma  will  immediately  be  suspected.  On  histological 
examination  in  the  vast  majority  of  cases,  gland  elements  will  be 
found  scattered  throughout  the  growth.  There  are  a  few  cases, 
however,  in  which  the  diffuse  growth  exists  and  yet  no  invasion  of 
glands  has  occurred.  The  following  cases  belong  to  this  group. 
In  Sanitarium  No.  1847  there  was  also  a  suppurating  submucous 
myoma.  In  Case  No.  12,221  the  increase  in  size  of  the  uterus  was 
due  in  part  to  a  diffuse  myomatous  thickening,  but  chiefly  to  a  recent 
pregnancy.  Even  in  cutting  the  uterus  open  adenomyoma  was 
suspected,  and  not  until  the  histological  examination  showed  no 
gland  invasion,  and  decidual  cells  were  demonstrated,  was  an  exact 
diagnosis  made. 

H.  A.  K.  Sanitarium  1847.    Path.  No.  8346. 

Diffuse  myomatous  thickening  of  both  the 
anterior  and  posterior  uterine  walls;  b  r  e  a  k  - 
i  n  g  d  o  w  n  o  f  a  submucous  myoma  with  suppu- 
ration, producing  in  all  probability  a  mild 
endometritis  of  the  body  and  of  the  cervix; 
normal  appendages  on  the  left  side;  Graafian 
follicle    c  y  s  t    on    the    right. 

W.  J.,  aged  thirty-four,  married.  Admitted  March  1,  1905; 
discharged  April  12,  1905.  The  patient  has  been  married  eleven 
years,  has  had  two  children  and  no  miscarriages.  Labors  normal. 
The  menses  have  been  irregular  and  profuse  for  the  last  year,  oc- 
curring every  three  weeks.  For  the  last  two  weeks  she  has  noticed 
a   vaginal  discharge.     The  patient   has  a   sallow  appearance;  the 

230 


DIFFUSE    MYOMATOUS   THICKENING    OF   THE    DTERUS  231 

haemoglobin  is  50  per  cent.    There  was  apparently  a  passage  of  a 

small  tumor  from  the  vagina  a  few  week.-  ago.  Since  then  there 
have  been  chills  and  fever  accompanied  by  a  good  deal  of  abdominal 
pain  in  the  region  of  the  ovaries. 

Path.  Xos.  8  346  and  8  3  46  J. —The  specimen  con- 
sists of  the  uterus,  about  twice  the  natural  size,  the  left  normal  tube 
and  ovary,  the  right  tube,  and  a  cystic  right  ovary.  The  body  of 
the  uterus  itself  is  10  cm.  in  length,  9  cm.  in  breadth,  and  8  cm.  in 
its  antero-posterior  diameters.  It  is  smooth  and  glistening.  The 
thickening  in  the  uterus  is  found  to  be  due  to  a  diffuse  thickening 
in  both  the  anterior  and  posterior  walls.  The  anterior  wall  varies 
from  2  to  4.5  cm.  in  thickness;  the  posterior  from  2  to  3  cm.  in  thick- 
ness; and  projecting  from  the  fundus  into  the  cavity  is  a  submu- 
cous myoma,  2.5  cm.  in  diameter.  In  the  vicinity  of  this  are  hard 
areas  rather  difficult  to  explain.  In  the  myoma  there  are  areas  of 
hyaline  transformation.  The  uterine  cavity  itself  is  6  cm.  in  length, 
the  mucosa  1  mm.  in  thickness.  At  first  it  looks  as  if  we  had  a  dif- 
fuse adenomyomatous  thickening  of  both  the  anterior  and  posterior 
walls,  but  at  no  point  macroscopically  is  one  able  to  trace  the  mucosa 
into  the  depth.  The  left  tube  and  ovary  are  normal.  The  right 
tube  is  normal.  The  ovary  is  somewhat  thickened  and  contains  one 
cyst,  approximately  4  cm.  in  diameter,  and  adjoining  this  is  an  oval 
cyst,  6  cm.  in  its  longest  diameter.  The  inner  surfaces  of  these  are 
perfectly  smooth,  and  one  would  have  soon  merged  into  the  other. 
They  seem  to  be  Graafian  follicle  cysts. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — The  cervical  glands 
are  in  places  much  dilated,  and  covering  the  surface  of  the  cervix 
are  here  and  there  quantities  of  polymorphonuclear  leucocytes  which 
have  come  down  from  the  body  of  the  uterus.  The  stroma  is  to  a 
slight  extent  infiltrated  with  small  round  cells.  There  is,  however, 
very  little  infiltration  of  the  cervix  itself  and  the  glands  in  the  depth 
are  perfectly  normal.  Sections  from  the  body  of  the  uterus  show  a 
submucous  myoma,  which  to  a  great  extent  has  been  transformed 
into  hyaline  material.  We  have  here  and  there  spindle  cells,  chiefly 
fibrous  in  character,  and  in  other  places  cells  which  have  taken  up 


232  ADENOMYOMA    OF   THE    UTERUS 

yellowish-brown  pigment,  evidently  the  remains  of  old  hemorrhages. 
Here  also  we  have  thrombosed  vessels.  The  surface  of  the  myoma 
consists  essentially  of  granulation  tissue  containing  polymorphonu- 
clear leucocytes  in  its  meshes,  and  covering  the  surface  are  fibrin 
and  quantities  of  leucocytes.  In  this  tissue  are  large  and  small 
blood-vessels.  The  majority  of  these  are  filled  with  fibrin  and 
leucocytes.  In  other  words,  there  has  been  coagulation  necrosis. 
At  no  point  do  we  find  any  evidence  of  glands  in  the  depth. 

Sections  from  the  larger  cyst  of  the  right  ovary  show  that  it  is 
lined  with  cuboidal  epithelium,  the  nuclei  being  situated  in  the 
middle  of  the  cells.  There  is  no  doubt  that  the  growth  is  a  Graafian 
follicle  cyst. 

Diagnosis  . — Diffuse  myomatous  thickening  of  both  the  an- 
terior and  posterior  uterine  walls;  breaking  down  of  a  submucous 
myoma  with  suppuration,  producing  a  mild  endometritis.  The 
appendix  in  this  case  shows  chronic  inflammation. 

Gyn.  No.  12,221.     Path.  No.  8832. 

Thickening  of  a  recently  pregnant  uterus 
which  clinically  gave  symptoms  simulating 
myoma.  The  uterus  on  removalwas  strongly 
suggestive  of  a  diffuse  a  d  e  n  o  m  y  o  m  a  t  o  u  s  con- 
dition. 

L.  D.,  aged  thirty-seven,  married,  white.  Admitted  July  7, 
1905;  discharged  August  4,  1905.  The  diagnosis  on  admission  was 
infected  submucous  myoma.  The  patient  began  to  menstruate  at 
fifteen,  was  regular  until  after  the  birth  of  her  first  child,  but  has  been 
somewhat  irregular  since  then.  She  has  been  married  for  eighteen 
years,  and  has  had  seven  children  and  one  miscarriage  at  the  eighth 
week,  a  year  and  a  half  ago.  She  had  some  irregular  bleeding  several 
months  ago.  Five  months  ago  she  ceased  bleeding,  but  the  last  two 
months  she  has  been  in  bed.  The  periods  recurred,  appearing  every 
two  or  three  weeks.  The  hemorrhages  were  profuse.  It  is  rather 
difficult  to  get  the  exact  date  of  the  last  period.  The  patient  has 
lost  9  pounds  in  the  two  weeks  previous  to  her  admission  to  the 


DIFFUSE    THICKENING    OF    PREGNANT    UTERI  -  233 

hospital.     Her  haemoglobin  is  02  per  cent,  unci  she  presents  a  rather 

emaciated  appearance. 

Ope  r  a  fc  i  o  o  .  Vaginal  hysterectomy.  The  highest  post- 
operative temperature  was  1()().2°  F.  She  made  a  satisfactory  re- 
covery. 

Path.  No.  8832. — The  specimen  consists  of  the  uterus. 
It  is  10  cm.  in  length,  7  cm.  in  breadth,  and  6  cm.  in  its  anteropos- 
terior diameters.  It  is  free  from  adhesions.  The  cervix  looks  nor- 
mal. The  posterior  uterine  wall  varies  from  1  to  3.5  cm.  in  thickness 
and  presents  a  coarse  appearance.  In  the  anterior  wall  the  mucosa 
is  2  mm.  in  thickness,  in  the  posterior  it  reaches  5.6  mm.,  where 
there  is  localized  thickening.  The  general  appearance  is  very  sug- 
gestive of  adenomyoma. 

On  histological  examination  the  cervix  is  found  to  present  a 
rather  suspicious  appearance.  We  have  an  intact  vaginal  epithe- 
lium, then  a  proliferation  of  the  cervical  epithelium,  the  glands 
having  formed  many  new  and  smaller  ones.  The  proliferation  in 
places  is  solid  and  here  suggests  squamous  epithelium.  At  other 
points  there  is  loss  of  the  surface  epithelium,  and  we  have  typical 
granulation  tissue.  There  has  evidently  been  an  inflammation  here, 
giving  rise  to  the  proliferation.  The  infiltration,  however,  is  not 
wide-spread,  as  in  the  underlying  stroma  it  is  not  extensive.  In  the 
body  of  the  uterus  the  mucosa  in  places  is  intact  and  the  glands  look 
normal  or  are  somewhat  dilated.  At  other  points  the  surface  con- 
sists entirely  of  necrotic  tissue  or  of  canalized  fibrin,  and  deeper  still 
are  small  glands  and  a  few  decidual  cells  in  the  stroma.  The  blood- 
vessels in  the  mucosa  show  a  marked  change.  The  cells  are  swollen 
and  are  typical  decidual  cells.  In  the  stroma  there  is  a  good  deal 
of  small  round-cell  infiltration  and  at  a  few  points  what  appear  to 
be  villi,  devoid  to  a  great  extent  of  their  epithelial  covering.  For  a 
short  distance  into  the  muscle  we  can  trace  glands,  and  deep  in  the 
muscle  there  are  what  appear  to  be  decidual  cells  together  with 
swollen  muscle  fibres. 

In  this  case,  as  seen  from  a  clinical  standpoint,  the  diagnosis  of 
probable  myoma  of  the  body  of  the  uterus  was  made.     The  uterus 


234  ADENOMYOMA  OF  THE  UTERUS 

was  enlarged  and  there  was  evidently  uterine  hemorrhage  and  a 
certain  amount  of  discharge.  Moreover,  the  menstrual  history 
was  not  satisfactory.  Even  after  the  uterus  had  been  removed  the 
thickened  wall  strongly  suggested  adenomyoma,  but,  as  we  see  on 
histological  examination,  there  are  typical  evidences  of  pregnancy. 
There  is  no  discrete  myoma,  although  there  is  a  definite  tendency 
toward  myomatous  thickening. 


CHAPTER  XXII 

ADENOMYOMATA  OF  THE  UTERINE  HORN 

Meyer  has  very  justly  divided  these  into  two  groups  according 
to  their  situation  and  source  of  origin.  The  uterine  mucosa  is  con- 
tinued up  into  the  cornu,  where  it  becomes  very  thin,  there  being 
merely  the  surface  epithelium,  a  small  amount  of  stroma  of  the 
mucosa,  and  a  few  "lands.  The  mucosa  becomes  still  thinner,  and 
at  the  interstitial  portion  of  the  tube,  which  is  within  the  uterine 
horn,  gradually  passes  over  into  the  tubal  epithelium.  This  epithe- 
lium is  identical  in  character  with  that  lining  the  uterine  cavity,  but 
the  peculiar  stroma  found  in  the  uterine  mucosa  is  entirely  wanting 
and  no  glands  are  present. 

ADENOMYOMATA  ARISING  FROM  THE  UTERINE  PORTION  OF  THE  UTERINE 

HORN 

These  consist  of  small  diffuse  thickenings  of  the  uterine  cornu. 
As  a  rule,  they  are  not  larger  than  1  centimetre  in  diameter,  but 
occasionally  may  reach  the  size  of  a  walnut  (Fig.  65,  p.  243).  They 
consist  of  gland-like  spaces,  usually  cystic,  and  are  surrounded  by 
a  diffuse  myomatous  muscle.  The  cysts  are  lined  with  cylindrical 
ciliated  epithelium  and  contain  desquamated  epithelium  and  blood. 
Where  the  glands  are  much  dilated,  they  may  lie  in  direct  contact 
with  the  myomatous  muscle,  but  the  smaller  ones  are  separated  from 
the  muscle  by  the  characteristic  stroma  of  the  mucosa.  The  myo- 
matous tissue  seems  to  be  circularly  arranged  around  the  gland 
spaces,  and  it  frequently  appears  as  if  the  myomatous  thickening 
was  due  almost  entirely  to  the  irritation  set  up  by  the  glands.  These 
myomata  may  In4  near  the  tube  lumen,  in  the  vicinity  of  tin1  peri- 
toneum or  lie  near  the  broad  ligament.  The  origin  of  the  gland  ele- 
ments was  referred  by  von  Recklinghausen  and  others  to  the  Wolf- 
fian duct,  but  in  the  last  few  years  their  continuity  with  the  uterine 

235 


236  ADEXOMYOMA    OF    THE    UTERI'S 

glands  has  been  traced,  and  it  is  probable  that  the  majority,  if  not 
all,  of  these  adenomyomata  owe  their  glandular  elements  to  the 
uterine  mucosa.  The  only  difference  between  these  and  the  diffuse 
growths  in  the  uterine  cavity  is  their  small  size  and  their  relative 
poverty  in  gland  elements.  When  we  remember  that  the  glands  in 
the  uterine  horn  are  few  and  far  between,  this  scanty  glandular 
distribution  is  readilv  understood. 


ADENOMYOMATA  FROM  THE  TUBAL  PORTION  OF  THE  UTERINE  HORN 

These  growths,  likewise  situated  in  the  uterine  horn,  also  con- 
sist of  small  myomata  containing  isolated  gland-like  spaces  or  small 
cj^sts.  These  spaces  are  lined  with  a  single  layer  of  cylindrical, 
ciliated  epithelium.  They  may  be  situated  in  the  inner  muscular 
layers  of  the  tube  or  penetrate  nearly  to  the  peritoneal  surface  on  the 
one  side,  or  to  the  mesosalpinx  on  the  opposite  side.  They  differ 
from  those  originating  in  the  uterine  portion  of  the  uterine  horn  in 
that  the  epithelium  rests  directly  on  the  muscle  instead  of  being- 
separated  from  it  by  the  characteristic  stroma  (Fig.  64,  p.  237). 
The  reason  for  this  was  at  first  sight  difficult  to  understand,  but 
after  von  Franque,1  Meyer,2  Gottschalk,3  and  Lockstaedt4  had  shown 
conclusively  that  the  gland-like  spaces  were  nothing  more  than  pro- 
longations outward  of  the  tubal  mucosa,  the  solution  was  clear,  as 
in  the  tubal  mucosa  the  characteristic  stroma  of  the  uterine  mucosa 
is  wanting.  The  origin  of  the  gland-like  spaces  in  these  growths 
was  likewise  formerly  attributed  to  remains  of  the  Wolffian  body, 
but  we  now  know  that  the  majority  of  these  represent  prolonga- 
tions outward  of  the  tubal  mucosa,  probably  followed  second- 
arily by  the  myomatous  development,  as  is  evidenced  by  the  fact 

1  Yon  Franque.  0.:  Salpingitis  nodosa  isthmiea  unci  Adenomyoma  Tubae. 
Centralbl.  f.  Gynaek.,  1900,  Bd.  xxv,  S.  660. 

2  Meyer:  Ztschr.  f.  Geburtshulfe  und  Gynaekologie,  Bd.  xlii,  H.  1. 

3  Gottschalk:  Demonstration  zur  Enstehung  der  Adenome  des  Tubenisthmus. 
Ztschr.  f.  Geburtshulfe  und  Gynaekologie,  1900,  Bd.  xlii,  S.  616. 

'  4  Lockstaedt,  Paul:    Ueber  Yorkommen  und  Bedeutung  von  Driisenschlauchen 
in  Myomen  des  Uterus.     Monatsschr.  f.  Geb.  u.  Gyn.,  1898,  Bd.  vii,  S.  188. 


A.DENOMYOMATA    OF   THE    UTERINE    IIOUN 


237 


that   those  outgrowths  are  often    found  independent    of  the  myo- 
matous growth. 

Clinically,  these  small  myomata  in  the  uterine  horns  are  of 
little  importance.  They  are  not  recognized  until  the  organ  has 
been  removed  for  some  other  cause,  usually  myomata  or  pus  tubes. 
For  a  period  of  over  five  years  (1893-1898)  we  had  sections  taken 


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Fig.  64. — Adenomyoma  of  the  oterine  horn.     (8  diameters.) 

Gyn.-Path.  No.  4  8  20.  o  is  a  cross-section  of  the  Fallopian  tube;  b  the  outer  or 
peritoneal  surface;  c  the  tissue  m>ar  the  broad  ligament.  Scattered  everywhere  throughout  the 
tissue,  which  under  a  higher  power  was  seen  to  be  myomatous,  are  round,  oval  or  irregular, 
elongate  glands,  occurring  singly  or  in  bunches.  These  were  lined  with  cuboidal  or  cylindrical 
epithelium  which  in  most  places  rested  directly  on  the  muscle.  This  appears  to  be  an  adeno- 
myoma originating  from  the  tubal  portion  of  the  uterine  horn. 

from  both  uterine  horns  as  a  routine  procedure,  and  found  groups 
of  these  gland-like  spaces,  with  or  without  myomatous  thickening, 
to  be  very  common. 


CASES  IN  WHICH  ADENOMYOMATA  WERE  DETECTED  IN  THE  UTERINE  HORN 

In  this  group  we  have  not  attempted  to  divide  the  cases  into 
those  originating  from  the  uterine  portion  of  the  horn  and  those 
derived  from  the  tubal  portion,  but  have  included  them  all  in  the 
same  class. 


238  ADENOMYOMA  OF  THE  UTERUS 

Gyn.  No.  11,572.     Path.  No.  7800. 

Subperitoneal  and  interstitial  uterine  my  - 
omata;  adenomyoma  of  the  left  uterine  horn; 
normal    appendages. 

R.  J.  R.,  aged  thirty-three,  black,  married.  Admitted  September 
27,  1904;  discharged  October  27,  1904.  The  patient  has  been  mar- 
ried thirteen  years,  but  has  never  been  pregnant. 

Operation  . — Hysterectomy.  The  patient  made  a  satis- 
factory recovery. 

Path.  No.  7800  . — The  specimen  consists  of  a  greatly 
enlarged  uterus  and  of  the  tubes  and  ovaries.  The  body  of  the 
uterus  is  normal  in  size,  but  springing  from  its  surface  are  several 
small  pedunculated  myomata.  In  the  left  uterine  horn  is  a  distinct 
thickening,  the  nodule  being  1.5  cm.  in  diameter.  The  tube  lies 
perfectly  free.  Attached  to  the  fundus  by  a  pedicle,  2.5  cm.  in 
diameter,  is  a  large  myomatous  tumor,  20  by  15  by  10  cm.  It  is 
irregular  and  nodular.  The  tumor  and  the  uterus  are  free  from 
adhesions.     The  appendages  are  apparently  normal. 

Sections  from  the  nodule  in  the  left  horn  show  what  appears  to 
be  the  lumen  of  the  tube  surrounded  by  several  definite  glandular 
areas.  Embedded  in  this  stroma  and  scattered  throughout  the 
nodule  is  a  diffuse  myoma.  There  are  gland  spaces  lying  in  direct 
contact  with  the  muscle.  These  glands  are  lined  with  one  layer  of 
high  cylindrical  epithelium.  They  appear  to  have  originated  from 
the  uterine  portion  of  the  tube,  although  it  is  impossible  to  state 
this  with  certainty. 

Diagnosis  . — Subperitoneal  and  interstitial  uterine  myomata. 
Adenomyoma  of  the  left  uterine  horn;  normal  appendages. 

Path.  No.  3721. 
A  small  uterus  with  somewhat  suspicious 
changes;  adenomyoma  of  the  left  uterine 
horn;  cystadenoma  of  the  right  ovary  with 
carcinomatous  changes;  cystadenoma  of  the 
left   ovary. 


ADENOMYOMATA    OF   THE    UTERINE    HORN  239 

The  specimen  consists  of  the  uterus,  both  tubes,  and  a  cysl  on 
each  side.  The  uterus  is  exceedingly  small  and  as  far  as  can  be 
determined  measures  4  cm.  in  Length,  3  cm.  in  breadth  and  1.1  cm. 

in  thickness.  The  uterine  walls  are  very  soft  and  wary  from  7  in 
9  mm.  in  thickness.  The  cavity  is  seen  as  a  slit -like  depression. 
It  is  3  cm.  in  length.  The  mucous  membrane  is  2  mm.  in  thickness. 
The  anterior  and  posterior  surfaces  of  the  uterus  are  smooth  save 
for  a  few  delicate  adhesions. 

On  histological  examination  the  uterine  mucosa  shows  marked 
senile  atrophy.  Its  surface  is  smooth.  The  glands  are  moderate 
in  amount  and  in  some  places  are  considerably  dilated.  The  epithe- 
lium, as  a  whole,  is  lower  than  usual.  The  glands  are  flattened. 
Some  are  irregularly  arranged  and  present  little  papillary  growths. 
Immediately  beneath  the  left  cornu  is  a  nodule.  This  is  com- 
posed of  myomatous  tissue  containing  glands  lined  wit h  a  l< >wc<  tlumnar 
epithelium  of  uniform  appearance.  On  the  right  side  there  is  a 
cystadenoma,  portions  of  which  show  carcinomatous  changes.  ( )n 
the  left  side  there  is  a  simple  cystadenoma. 

Diagnosis  . — Small  uterus  with  suspicious  change :  adeno- 
myoma  in  the  left  uterine  horn;  cystadenoma  of  the  right  ovary 
with  carcinomatous  change;   cystadenoma  of  the  left  ovary. 

Gyn.  No.  6635.     Path.  No.  2845. 

A  d  e  11  o  m  y  o  m  a  in  the  u  t  e  r  i  n  e  h  0  r  n  w  i  t  h  c  0  m  - 
m  e  11  c  i  n  g   subperit  0  n  e  a  1   a  d  eno  m  y  o  ma  . 

P.,  aged  thirty,  white.  Operation,  January  14,  1899.  Sections 
from  the  uterine  wall  show  that  the  mucosa  reaches  5  mm.  in  thick- 
ness. An  oblique  section  through  the  stump  of  the  right  tube  shows 
a  small  lumen  of  the  tube  with  irregular  outlines,  lined  with  normal, 
low,  cylindrical,  epithelial  cells.  Situated  some  distance  from  the 
tube,  surrounded  by  a  definite  circular  zone  of  muscle,  is  an  island 
of  mucosa,  perfectly  normal  in  character.  This  is  surrounded  in 
numerous  places  by  irregular  glands  lined  with  cylindrical  epithe- 
lium and  filled  with  desquamated  epithelium  and  old  hemorrhage. 
We  have  here  the  foundation  for  a  subperitoneal  adenomyoma. 


240  ADENOMYOMA  OF  THE  UTERUS 

Gyn.  No.  3805.    Path.  No.  892. 

The  tube  at  the  uterine  horn  is  re  presented 
by   three   gland    spaces   instead    of    a   lumen. 

M.  W.,  aged  thirty-one.  September  22,  1895.  Pathological 
diagnosis :  Right  hydrosalpinx,  left  perisalpingitis,  gland-like  spaces 
in  the  uterine  cornu.  We  have  sections  from  the  left  uterine  horn. 
The  uterine  horn  is  represented  by  three  glands  instead  of  a  lumen, 
a  very  unusual  picture.  This  is  readily  recognized,  as  we  have  the 
two  definite  layers  of  muscle  surrounding  them.  We  have  here 
gland-like  spaces  which  are  irregular  or  round,  some  of  them  oblong. 
They  are  lined  with  cylindrical  epithelium  and  characteristic  stroma. 
This  is  the  first  case  in  which  on  examination  of  the  uterine  horn 
we  have  found  the  lumen  represented  by  three  distinct  spaces. 

Gyn.  No.  3715.    Path.  No.  843. 

Adenomyoma   of   the  uterine  horn. 

E.  S.,  white.  August  15,  1895.  Diagnosis:  Remnants  of  an 
old  endometritis;  commencing  abscess  in  the  right  uterine  cornu; 
gland-like  spaces  in  the  uterine  cornu;  double  perisalpingitis;  double 
perioophoritis.  On  examination  of  sections  from  the  left  uterine 
horn  we  find  in  the  upper  part  a  few  small  gland-like  spaces  a  short 
distance  beneath  the  peritoneum.  These  are  round  or  oblong  on 
cross-section  and  beneath  the  tube  we  also  find  some  gland  spaces. 
All  the  glands  are  lined  with  cylindrical  epithelium.  Some  of  them 
are  rather  complex,  and  instantly  suggest  an  origin  from  a  Wolffian 
duct;  others  resemble  uterine  mucosa.  The  tube  lumen  is  much 
degenerated  and  is  filled  with  pus. 

Gyn.  No.  3395.    Path.  No.  649. 

Partial  atrophy  of  the  uterine  mucosa; 
gland -like  spaces  in  the  uterine  horn.  Right 
side:  chronic  salpingitis,  miliary  abscess 
of  the  ovary.  Left  side:  chronic  salpingitis 
and   perioophoritis. 

H.,  white.     March  30,    1895.     Sections  from  the  uterine   horn 


A.DENOMYOMAXA    OF   THE    [JTERINE    HORN  24] 

show  numerous  adhesions  and  some  gland-like  spaces.  These  are 
small  and  round  on  cross-section.  They  are  lined  with  cylindrical 
or  cuboidal  epithelium  and  are  filled  with  desquamated  epithelium. 

They  lie  in  direct  contact  with  the  muscle.  Tlie  tissue  is  evidently 
the  seat  of  chronic  inflammation,  as  is  evidenced  by  the  presence  of 

many  small  round  cells.  Sections  from  the  left  tube  show  only  one 
or  two  gland-like  spaces  and  there  is  much  less  evidence  of  inflam- 
matory  reaction. 

Gyn.  No.  3401.     Path.  No.  647. 

Partial  a  t  r  o  p  h  y  of  t  h  e  u tori n  e  m u  c  o  s  a  . 
gland-like  spaces  in  both  uterine  horns,  ac- 
cessory ostium  of  the  right  tube,  large  simple 
hydrosalpinx  of  the  left  tube;  slight  ad- 
hesions  on   both   sides. 

Examination  of  the  uterine  cornu  with  the  low  power  is  most 
confusing  at  first,  and  one  is  hardly  able  to  recognize  the  cross- 
section  of  the  tube.  Surrounding  the  tube  on  all  sides,  but  particu- 
larly between  the  tube  and  the  peritoneum  covering  the  surface,  are 
colonies  of  glands.  Covering  one  surface  are  numerous  adhesions 
consisting  chiefly  of  omentum.  The  gland-like  spaces  to  a  great 
extent  communicate  with  one  another,  as  is  evidenced  by  the  little 
bridges  here  and  there.  Some  of  the  gland  spaces  lie  almost  beneath 
the  peritoneum  and  seem  to  be  foreign  to  the  uterus.  The  majority, 
however,  are  in  direct  contact  with  it.  They  are  lined  with  cuboidal 
or  cylindrical  epithelium.     The  picture  is  a  most  interesting  one. 

On  the  left  side  sections  from  the  cornu  show  a  similar  condition, 
although  the  picture  is  not  so  confusing.  We  are  able  to  trace  a 
definite  channel  which  looks  very  much  as  if  it  were  an  outgrowth 
of  the  uterine  mucosa.  In  this  case  we  have  a  portion  of  adeno- 
myomatous  tissue  definitely  (ait  off  and  forming  an  independent 
subperitoneal  adenomyoma.  In  none  of  these  do  we  find  much 
evidence  of  stroma. 

Hi 


242  ADEXOMYOMA  OF  THE  UTERUS 

C.  H.  I.  No.  1517.     Path.  No.  10,669. 

Adenomyoma  in  both  uterine  horns  (Fig.  65) ; 
diffuse  adenomyoma  of  the  uterus;  minia- 
ture  uterine   cavity. 

S.  E.  W.,  married,  aged  forty-three.  Admitted  December  2, 
1906.  The  patient  has  not  been  well  for  the  last  five  or  six  years. 
Her  periods  during  this  time  have  been  profuse,  at  times  lasting  as 
long  as  twelve  days.  She  has  had  no  children  and  no  miscarriages. 
She  has  had  some  retention  of  urine  at  times;  at  other  times  there 
is  frequency  of  micturition.  There  has  been  leucorrhcea  for  five 
or  six  years. 

Operation  . — Hystero-myomectomy  and  appendectomy. 
The  patient  made  a  satisfactory  recovery.  The  highest  post-opera- 
tive temperature  was  101.6°  F. 

Path.  No.  10,669  . — The  specimen  consists  of  a  multi- 
nodular, myomatous  uterus,  10  cm.  in  length,  13  cm.  in  breadth, 
and  11  cm.  in  its  antero-posterior  diameters.  The  uterus  is  every- 
where smooth  and  glistening.  The  increase  in  size  is  due  to  sub- 
peritoneal, interstitial,  and  submucous  myomata.  The  largest 
nodule,  8  cm.  in  diameter,  is  situated  anteriorly  and  to  the  right. 
The  uterine  cavity  is  very  small  and  is  much  distorted.  In  the 
left  uterine  horn  is  an  area  of  thickening  (Fig.  65).  This  is  directly 
continuous  with  the  tube  and  is  4  cm.  in  length,  and  varies  from  1  to 
2.5  cm.  in  breadth.  It  appears  to  be  cystic  and  on  section  presents 
a  sieve-like  or  polypoid  appearance.  There  are  also  irregular  cystic 
spaces,  varying  from  1  to  5  mm.  in  diameter.  At  least  seven  or 
eight  of  these  are  seen  in  one  cross-section.  The  right  tube  is 
occluded,  and  reaches  4  cm.  in  diameter.  The  ovary  is  slightly 
mutilated.  The  right  tube  at  the  uterine  horn  presents  an  area  of 
thickening  1.5  cm.  in  diameter.  On  section  this  horn  is  also  seen  to 
contain  cystic  spaces,  one  of  them  at  least  3  mm.  in  length. 

Histological  Examination  . — Sections  taken  from 
the  right  uterine  horn  show  a  most  instructive  picture.  Cross- 
section  of  the  tube  shows  that  it  is  perfectly  normal.  Just  to  one 
side  is  a  miniature  uterine  cavity  lined  with  one  layer  of  epithelium. 


A.DENOMYOMATA    OF    THE    UTERINE    llo|{\ 


243 


In  oilier  portions  there  are  numerous  uterine  glands,  the  majority 
of  which  are  dilated.     Some  lie  in  direcl  contact  with  the  muscle. 

Others  are  separated  from  it  by  a  small  amount  of  stroma.  A  most 
interesting  picture  is  noted  in  some  places,  namely,  that  the  bunches 
of  uterine  glands  are  surrounded  by  a  circular  layer  of  myomatous 


96 


,■ 


$*■ 


V/ 


■/M 


J 


<?■ 


#*-:w 


Fig.    65. — Adenomyoma   of   both    uterine   horns;    discrete   myomata;     diffuse    adeno- 
myoma  of  the   UTERUS,      (j  natural  size.) 

C.  H.  I.  No.  1517.  Gyn.-Path.  No.  10.669.  Occupying  the  uterus 
several  myomatous  nodules.  The  left  tube  is  the  seat  of  a  hydrosalpinx:  it  is  firmly  fixed  to  the 
ovary  and  to  the  surface  of  the  uterus.  At  the  left  uterine  horn  is  a  definite  thickening.  This  ana 
appeared  cystic  and  on  making  an  incision  from  a  to  a'  the  picture  in  B  was  found.  The  cysl 
-paces  were  irregular  in  form  and  varied  from  1  to  5  nun.  in  diameter.  A  similar  and  smaller 
cystic  tumor  was  present  at  the  right  uterine  horn,  as  indicated  by  c.  This  on  examination  pre- 
sented the  same  picture  as  did  that  of  the  left.  On  histological  examination  the  thickenings  in 
both  horns  were  found  to  be  due  to  the  presence  of  adenomyoma.  The  glands  were  of  the  uterine 
type  and  in  many  places  were  surrounded  by  the  characteristic  stroma  of  the  mucosa. 

C  was  a  typical  miniature  uterine  cavity.      The  uterine  walls  were  the  -cut  of  a  diffuse  adenomyoma. 


tissue.  Riddling  the  mucosa  everywhere  at  the  uterine  horn  are 
uterine  glands  occurring  singly  or  in  bunches.  Near  the  peritoneal 
surface,  as  noted  macroscopically,  some  of  the  glands  reach  2  mm. 
or  more  in  diameter.  The  gland  cavities  in  places  contain  desqua- 
mated epithelium  and  the  epithelium  has  taken  up  blood-pigment 


244  ADENOMYOMA  OF  THE  UTERUS 

and  some  polymorphonuclear  leucocytes.  The  origin  of  these  glands 
it  is  impossible  to  determine. 

Sections  from  the  left  uterine  horn  also  show  many  cyst  spaces, 
as  noted  macroscopically.  Some  of  these  reach  3  mm.  or  more  in 
diameter.  They  may  be  circular,  oval,  or  irregular  in  shape,  and 
looking  at  the  specimen  macroscopically  one  sees  islands  of  uterine 
mucosa  surrounded  by  a  definite  and  well-defined  zone  of  muscle. 
With  the  low  power  we  find  the  large  cyst  spaces  lined  with  one 
layer  of  epithelium  resting  directly  on  the  muscle.  Such  cyst 
spaces  may  be  found  beneath  the  peritoneum.  At  other  points 
are  colonies  of  glands,  and  in  the  depth  we  find  typical  islands  of 
normal  uterine  mucosa,  many  of  which  are  surrounded  by  the  char- 
acteristic stroma.  It  is  impossible  to  definitely  determine  the 
origin  of  these  glands  in  the  lower  portion.  The  gland-like  spaces 
are  either  empty  or  filled  with  desquamated  epithelium  and  swollen 
cells  that  have  taken  up  pigment. 

Diagnosis  . — Adenomyoma  in  both  right  and  left  uter- 
ine horns.  In  this  case  the  uterine  mucosa  has  everywhere  riddled 
the  myomatous  uterine  walls. 

Gyn.  No.  3399.    Path.  No.  645. 

Slight  atrophy  of  the  uterine  mucosa; 
small  interstitial  uterine  myomata;  gland- 
like spaces  in  the  uterine  cornu.  Small  ab- 
scess in  the  cornu.  Right  side:  chronic 
salpingitis;  general  adhesions.  Left  side: 
adhesions  and  a  small  cyst  springing  from 
the   left   ovary. 

The  interest  lies  in  the  fact  that  only  one  tube  is  involved. 

B.,  aged  twenty -four,  colored.     March  28,  1895. 

Sections  from  the  right  uterine  cornu  show  with  the  low  power 
several  gland-like  spaces  between  the  cross-section  of  the  tube  and 
the  peritoneal  surface.  They  lie  about  2  or  3  mm.  from  the  lumen. 
The  majority  of  them  are  irregular  and  are  lined  with  cuboidal  or 
cylindrical  epithelium.     One  of  these  cysts  in  several  places  has 


AI)i;\o.MV().MA'IA    OF   THE    UTERINE    HORN  245 

stroma  projecting  into  it.  These  are  covered  with  somewhal  flat- 
tened epithelium  and  the  cavities  contain  a  few  polymorphonuclear 

leucocytes.  There  are  also  numerous  other  minute  glands  Lined 
with  cylindrical  epithelium  and  Lying  in  direct  contacl  with  the 
muscle. 

Gyn.  No.  3379.     Path.  No.  633. 

The  uterine  mucosa  is  normal,  but  con- 
tain s  n  u  m  e  r  o  us  1  y  m  p  h  o  i  d  n  o  d  u  1  e  s  ;  g  land-like 
spaces  in  adhesions  over  t  h  e  u  tori  n  e  c  o  r  n  u  ; 
g  1  a  n  d  - 1  i  k  e  spaces  i  n  the  uterine  eornu;  gen- 
eral pelvic  adhesions;  a  small  cyst  of  the 
ovary,   probably   from  a   Graafian   follicle. 

On  examination  of  the  right  uterine  horn  the  spaces  are  of  little 
interest,  but  on  the  left  side,  where  the  section  represents  a  field 
closer  to  the  uterus, — in  other  words,  where  the  tube  is  jusl  begin- 
ning,— we  have  gland-like  spaces  practically  just  beneath  the  ad- 
hesions of  the  peritoneal  surface.  They  are  lined  with  cylindrical 
epithelium.  A  little  beneath  the  peritoneum  and  running  into 
the  muscle  is  a  similar  gland  space  lined  with  a  definite  layer  of 
cylindrical,  ciliated  epithelium  and  surrounded  by  a  zone  of 
lymphoid  cells.  Lying  at  the  lower  level,  even  with  the  tube,  are 
irregular  gland  spaces  lined  with  a  similar  epithelium  and  filled  with 
blood,  while  still  further  down  are  irregular  spaces  which  com- 
municate with  one  another  and  are  likewise  filled  with  blood. 
The  latter  bear  a  striking  resemblance  to  those  in  the  uterine 
mucosa,  although  they  have  no  definite  stroma  surrounding  them. 


CHAPTER  XXIII 

PREGNANCY  IN  THE  LEFT  FALLOPIAN  TUBE;   DISCRETE  UTERINE 

MYOMATA ;  DIFFUSE  ADENOMYOMA  IN  THE  RIGHT  UTERINE 

HORN  WITH  THE  DEVELOPMENT  OF  DECIDUAL  CELLS 

AROUND  THE  GLANDS  IN  THE  ADENOMYOMA 

This  case  was  particularly  interesting  from  a  clinical  standpoint, 
as  we  were  able  to  make  a  diagnosis  of  tubal  pregnancy  from  the 
velvety  feel  of  the  tube.1  From  a  histological  and  etiological  point 
of  view  the  transformation  into  decidua  of  the  stroma  of  the  glands 
of  the  adenomyoma,  in  the  uterine  horn  on  the  opposite  side  from 
tubal  pregnancy,  is  in  itself  strong  presumptive  evidence  that  these 
glands  are  derivatives  of  the  uterine  mucosa. 

Gyn.  No.  12,380.     Path.  No.  9281. 

Subperitoneal  and  interstitial  uterine 
myomata;  gland  hypertrophy  of  the  endome- 
trium with  extension  of  the  uterine  glands 
into  the  depth.  Pregnancy  in  the  left  Fal- 
lopian tube  (Fig.  66 J .  Diffuse  adenomyoma  in 
the  right  uterine  horn  with  decidual  cell 
formation  in  the  stroma  of  the  adenomyo- 
ma t  o  u  s   area. 

E.  P.,  aged  thirty,  colored.  Admitted  September  19;  discharged 
October  26,  1905.  Complaint :  uterine  hemorrhage,  pain  in  the  back 
and  right  side  for  seventeen  days.  Her  menses  began  without  dis- 
turbance at  fifteen  and  were  regular  for  two  years.  The  periods 
were  at  first  painless.  At  present  the  flow  usually  lasts  from  six 
to  eight  days.  Her  last  period  occurred  on  August  24th  and  the 
previous  one  in  July. 

The  patient  has  been  married  fourteen  years  and  has  had  no 

1  Cullen,  Thomas  S.:  The  Velvety  Feel  of  an  Unruptured  Tubal  Pregnancy. 
Johns  Hopkins  Hospital  Bulletin,  1906,  p.  154. 

246 


DECIDTLA    IN    AlDENOMYOMA    OF    I'll!.    UTERINE    HORN  24i 

children.     There  was  a  miscarriage  al  the  second  month  tour  years 
ago. 

On  examination  under  anaesthesia  1  made  out  definite  myo- 
matous nodules  in  the  uterus  and  on  the  left  side  a  thickening  differ- 
ing materially  from  the  nodules  in  the  uterus.     The  nodule  on  the 


Fig.   *i(3. — Left  tubal  pregnancy;      discrete    dterine    myomata;     adenomyoma  of  the 

RIGHT     UTERINE     BORN     WITH     DECIDUAL     FORMATION    IX    THE     stroma    SURROUNDING     l'HK 
GLANDS.      I 1  natural  size.) 

G  y  n  .   No.    1  2  ,  3  S  0  .      Ci  y  n  .  -  P  a  t  h  .   '.»  281  .      The  uterus  is  occupied  by  several 

small  subperitoneal  and  interstitial  myomata.  The  left  tube  contains  an  unruptured  pregnancy 
(a  |.  The  surface  of  the  tube  is  covered  with  markedly  dilated  blood-vessels.  In  the  righl  uterine 
honi  are  two  small  nodular  thickenings  which  encroach  upon  the  tube.  Histological  examination 
showed  that  they  were  adenoniyomata.  The  stroma  around  many  of  the  glands  had  been  eon- 
verted  into  typical  decidua. 


left  side  on  gentle  palpation  gave  the  impression  o(  being  rather  soft. 
hut  on  firm  pressure  was  found  to  be  hard.  In  other  words,  it  had 
a  velvety  feel.  On  account  of  this  peculiar  sensation  imparted  to 
the  examining  ringer  I  made  a  diagnosis  of  tubal  pregnancy  in 
addition  to  uterine  myomata. 

0  p  e  rati  o  n  .-  Hystero-myomectomy,  double  salpingectomy. 


248  ADENOMYOMA  OF  THE  UTERUS 

The  left  tube  had  not  yet  ruptured.  The  patient  made  a  satis- 
factory recovery. 

Path.  No.  9281  . — The  specimen  consists  of  a  myo- 
matous uterus  and  of  the  tubes.  The  uterus  is  approximately  10  cm. 
in  breadth,  10  cm.  in  length,  and  7  cm.  in  its  antero-posterior  diam- 
eter (Fig.  66).  Projecting  from  the  surface  are  several  myomatous 
nodules.  The  largest  is  3.5  cm.  in  diameter.  Scattered  throughout 
the  uterine  walls  are  several  smaller  nodules.  Covering  the  surface 
of  the  uterus  posteriorly  are  numerous  adhesions.  The  uterine 
cavity  is  6  cm.  in  length.  The  mucosa  is  thickened,  in  places  reach- 
ing 5  mm. 

In  the  right  uterine  horn  is  a  nodular  thickening  2.5  cm.  in  di- 
ameter. This  is  at  the  seat  of  the  tubal  attachment.  The  outer 
end  of  the  tube  is  free  from  adhesions. 

On  the  left  side  of  the  uterus  is  a  globular  thickening,  4  cm.  in 
diameter.  It  is  smooth  and  covered  over  with  dilated  vessels.  The 
central  portion  is  filled  with  blood  and  placental  tissue.  The  fim- 
briated end  of  the  tube  is  intact. 

Histological  Examination  . — Sections  from  the 
endometrium  show  typical  gland  hypertrophy.  There  is  little  evi- 
dence of  decidual  formation.  Here  and  there  the  glands  extend  a 
short  distance  into  the  muscle.  Sections  from  the  right  cornu  show 
diffuse  myomatous  thickening.  We  have  in  many  places  glands 
lying  in  direct  contact  with  the  muscle.  The  gland  epithelium  is 
cylindrical  and  here  and  there,  where  dilatation  has  taken  place,  the 
cells  are  flattened  or  are  almost  round.  The  gland  cavities  contain 
desquamated  epithelium,  a  few  polymorphonuclear  leucocytes, 
some  blood,  and  coagulated  serum.  At  other  points  the  glands  show 
budding,  and  in  numerous  places  there  is  a  typical  gland  hyper- 
trophy. This  gland  hypertrophy  is  especially  noticeable  where  the 
glands  are  surrounded  by  the  characteristic  stroma  of  the  mucosa. 
These  places  show  a  most  instructive  picture.  The  stroma 
cells  are  swollen  and  have  undergone  typical 
decidual  cell  formation.  Between  these  decidual 
cells  are  a  good  many  small  round  cells  and  here  and  there  a  few  poly- 


DECIDILA    IN    A.DENQMYOMA    OF   THE    UTERINE    HORN  249 

morphonuclear  leucocytes.  The  gland  epithelium  at  such  point-  is 
also  cuboidal  or  flat.  We  also  have  stems  of  stroma  projecting 
into  some  of  the  glands.  These  stems  are  covered  over  by  one  layer 
of  epithelium,  and  the  stroma  cells  are  bo  swollen  thai  they  might 
very  readily  be  mistaken  for  placental  tissue.  Some  of  the  glands 
are  gathered  in  groups  and  are  surrounded  by  parallel  and  circular 

layers  of  muscle  fibres. 

The  left  tube  is  the  seat  of  a  typical  tubal  pregnancy. 

Diagnosis. — Subperitoneal  and  interstitial  uterine  myo- 
mata;  pregnancy  in  the  left  Fallopian  tube;  diffuse  adenomyoma 
in  the  right  uterine  horn,  showing  decidual  formation  and  also 
gland  hypertrophy. 

This  is  a  most  instructive  case.  We  have  in  many  instances 
been  able  to  trace  the  extension  of  the  gland  elements  in  the  adeno- 
myoma from  the  uterine  mucosa.  In  this  case  we  have  an  adeno- 
myoma of  the  uterine  horn  and  the  stroma  elements  surrounding 
the  glands  have  taken  on  a  sympathetic  decidual  development,  just 
exactly  as  does  the  uterine  mucosa  at  times  when  tubal  pregnancy 
exists.  This  is  another  point  convincing  us  that  even  where  we 
are  unable  to  trace  the  direct  continuity  between  the  uterine  mucosa 
and  the  gland  elements  in  an  adenomyoma  they  are  in  all  probability 
derived  from  the  same  source,  because  they  react  in  precisely  the 
same  manner  as  does  the  normal  uterine  mucosa ;  and,  furthermore, 
they  pour  out  their  quota  of  menstrual  blood  at  the  period,  as  is 
evidenced  by  the  fact  that  many  of  the  glands  are  filled  and  mark- 
edly dilated  with  blood  either  recent  or  old. 


CHAPTER  XXIV 
ADENOMYOMA  OF  THE  ROUND  LIGAMENT 

Tumors  of  this  character  are  comparatively  rare,  and  until  the 
publication  of  our  case  in  May,  1896,  this  pathological  condition 
seems  to  have  been  unknown.  Similar  cases  have  since  been  report- 
ed by  Pfannenstiel,1  Blumer,2  Bluhm,3  Meyer,4  Aschoff,5  and  others. 
Such  a  growth  may  vary  from  1  to  2  or  3  cm.  in  diameter  and  is 
usually  situated  near  the  external  inguinal  ring.  It  consists  of  a 
very  firm  nodule,  coarse  in  texture  and  intimately  blended  with  the 
surrounding  adipose  tissue.  On  section  it  usually  presents  the  pic- 
ture of  a  diffuse  myoma,  and  the  fibres  can  be  seen  spreading  out 
into  the  adjoining  tissue  (Fig.  67,  p.  256).  Scattered  throughout 
this  coarse  tissue  are  cyst-like  spaces  varying  from  a  pinhead  to 
several  millimetres  in  diameter.  They  may  be  irregularly  oval  or 
slit-like.  Their  inner  surfaces  are  smooth  and  their  cavities  usually 
contain  chocolate-colored  contents.  Yellowish  or  brownish  pig- 
mented areas  are  also  frequently  noted. 

On  histological  examination  the  framework  of  these  growths  is 
found  to  be  composed  of  non-striped  muscle  fibres  forming  a  dense 
irregular  network  and  very  suggestive  of  the  diffuse  myomata  of 
the  uterus.  Occasionally,  however,  as  in  Aschoff 's  case,  the  major 
portion  of  the  growth  may   consist  of  fibrous  tissue.     Scattered 

1  Pfannenstiel :  Ueber  die  Adenome  des  Genitalstranges.  Verhandlungen  der 
Deutschen  Gesellschaft  fur  Gyn.,  1897. 

2  Blumer:  A  Case  of  Adenomyoma  of  the  Round  Ligament.  American  Journal 
of  Obstetrics,  1898,  xxxvii,  p.  37. 

3  Bluhm,  Agnes:  Zur  Pathologie  des  Ligamentum  Rotundum  Uteri.  Arch, 
f.  Gynaek.,  1898,  lv,  S.  647. 

4  Meyer:  Ueber  Driisen,  Cysten,  und  Adenome  im  Myometrium  der  Erwach- 
senen.     Ztschr.  f.  Geb.  Gyn.,  1900,  xliii,  S.  329. 

5  Aschoff ,  L.:  Cystisches  Adenofibrom  der  Leistengegend.  Monatschr.  f. 
Geburtshiilfe  und  Gynaekologie,  1899,  ix,  S.  25. 

250 


ADKNUMYOMATA    OF   THE    ROUND    LIGAMENT  251 

throughout  the  diffuse  myoma  arc  islands  of  glands,  round  on  cross- 
sectiou  (Fig.  68,  p.  257),  or  irregular  in  form.  They  arc  lined  with 
one  layer  of  cylindrical,  ciliated  epithelium  and  the  gland  cavities 
are  frequently  filled  with  blood.     These  glands  are  surrounded  by  a 

stroma  identical  with  that  of  the  uterine  mucosa.  The  gland 
epithelium  and  also  the  stroma  cells  often  contain  yellowish  or  brown 
granular  pigment.  The  cyst-like  spaces,  noted  macroscopically, 
are  likewise  lined  with  a  single  layer  of  cylindrical  ciliated  epithelium 

and  the  chocolate-colored  contents  are  the  remnants  of  old  hemor- 
rhages. All  of  the  adenomyomata  so  far  reported  have  the  same 
general  characteristics.  In  our  case"  nodules  were  found,  both  in 
the  right  and  in  the  left  round  ligaments. 

Pfannenstiel  found  such  a  growth  in  the  right  inguinal  region, 
and  in  the  same  case  a  second  in  the  vaginal  vault.  In  Blumer's 
case  there  were  primarily  two  distinct  nodules  in  the  righl  groin, 
each  about  6  mm.  in  diameter.  These  had  gradually  coalesced,  and 
at  the  expiration  of  twenty-three  years  formed  a  nodule  the  size  of 
a  hen's  egg.  In  Aschoff's  case  the  nodule  was  situated  in  the  left 
labium  majus,  and  when  first  observed  was  no  larger  than  a  pea. 
It  gradually  became  as  large  as  an  almond,  and  at  one  point  was  in 
close  proximity  to  the  skin.  Bluhm's  patient  had  a  firm  elastic 
tumor  the  size  of  a  plum  and  situated  at  the  internal  inguinal  ring. 
As  was  noted  in  Pfannenstiel's  case,  besides  the  nodule  in  the  in- 
guinal region,  there  was  a  second,  similar  in  character,  situated  in 
the  vaginal  vault.  Cases  of  this  character  have  also  been  reported 
by  von  Hern2  and  Pick.3  In  Pick's  case  the  myoma  was  as  large 
as  a  hazelnut  and  situated  in  the  posterior  vaginal  vault. 

The  foregoing   cases  are  definite  examples  of  adenomyomata, 

1  (Allien.  Thomas  S.:  Adenomyoma  of  the  Round  Ligament.  Johns  Hopkins 
Hospital  Bulletin,  .May.  1896;  Further  Remarks  on  Adenomyoma  <>f  the  Round 
Ligament.     Johns  Hopkins  Hospital  Bulletin,  1898. 

2  Von  Herff:  Ueber  Cystomyome  und  Adenomyome  der  Scheide.  Verhand- 
lungen  der  Deutschen  Gesellsch.  f.  Gyn.,  L897. 

3  Pick,  Ludwig:  Die  Adenomyome  der  Leistengegend  und  des  hinteren  Schei- 
dengewolbes;  ihre  Stellung  zu  den  paroophoralen  Adenomyomen  der  Uterus  und 
Tubenwandung,  v.  Recklinghausen's  Arch.  f.  Gynaek..  Bd.  lvii,  461. 


252  ADENOMYOMA    OF    THE    UTERUS 

and,  as  noted,  the  tumor  may  be  situated  in  one  or  both  round  liga- 
ments, in  the  labium  majus  or  in  the  posterior  vaginal  vault;  or 
such  growths  may  occur  simultaneously  in  the  inguinal  region  and 
vaginal  vault. 

Clinical  History  . — These  nodules  are  usually  of  slow 
growth.  In  our  own  case  it  had  been  present  eight  years ;  in  Blumer's 
case  for  twenty -three  years.  The  tumors  may  appear  as  early  as 
the  twentieth  year,  as  in  Blumer's  case,  or  as  late  as  the  forty-second 
year,  as  noted  in  Aschoff's  case.  Thej^  are  most  common  during  the 
child-bearing  period.  The  tumor  at  first  causes  little  annoyance, 
but  with  its  increase  in  size  there  is  pain  on  walking,  probably  on 
account  of  the  intimate  association  of  the  tumor  with  the  surround- 
ing structures,  as  well  as  considerable  distress  on  menstruation.  At 
the  period  the  lump  may  be  increased  in  size  and  become  very  pain- 
ful, again  diminishing  in  size  after  the  flow  is  over. 

Prognosis  . — Our  case  was  of  eight  years'  duration,  and 
on  histological  examination  gave  no  sign  of  malignancy,  proving 
that  the  growth  was  benign  in  character.  Blumer's  case  is  even 
more  convincing,  as  it  had  been  under  observation  twenty- three  years, 
the  growth  in  that  time  not  becoming  larger  than  a  hen's  egg. 
Microscopic  examination  also  showed  its  harmless  character. 

Treatment  . — Excision  of  the  nodule  is  indicated  solely 
on  account  of  the  discomfort  produced  by  its  presence. 

ORIGIN  OF  ADENOMYOMATA  OF  THE  ROUND  LIGAMENT 

As  in  the  case  of  adenomyomata  of  the  uterus,  controversy  has 
arisen  as  to  whether  the  growths  are  derivatives  of  the  Wolffian  or 
of  the  Mullerian  duct.  Many  authors  claim  that  portions  of  the 
Wolffian  duct  have  been  nipped  off  during  the  development  of  the 
embryo  and  have  been  carried  down  the  round  ligament,  and  that  in 
after-life  they  develop.  They  base  their  assumption  on  the  fact  that 
the  Wolffian  duct  comes  in  close  contact  with  the  round  ligament 
prior  to  its  descent  to  the  inguinal  region.  They  also  think  that  the 
gland  elements  of  the  adenomyoma  bear  some  resemblance  to  por- 
tions of  the  Wolffian  duct.     Those  dissenting  from  this  view  hold 


A.DENOMYOMATA    OF   THE    ROUND    LIGAMENT  253 

thai  there  is  strong  evidence  that  misplaced  portions  of  Miiller's 
duct  are  responsible  for  the  growth  of  these  tumors.  As  has  been 
noted,  the  glands  in  these  adenomyomata  cannot  be  distinguished 
in  many  instances  from  normal  uterine  glands.  They  are  small, 
round,  and  lined  wit  h  cylindrical  ciliated  epithelium.  Furthermore, 
they  are  surrounded  by  the  characteristic  stroma  of  the  normal 
uterine  mucosa.  Clinically,  it  has  been  noted  that  these  growths 
may  have  a  sympathetic  relationship  with  the  menstrual  period,  as 
seen  in  their  increase  in  size  at  thai  time,  followed  in  the  intermen- 
strual period  by  a  diminution  in  their  volume.  This  increase  in 
size  is  undoubtedly  due  to  the  hemorrhage  into  the  glands  at  the 
periods,  as  is  proved  by  the  hemorrhagic  contents  at  operation.  In 
our  case  menstruation  had  commenced  on  May  18th  and  ceased  on 
May  23d  or  just  three  days  before  operation;  and  on  making  sections 
the  glands  were  found  filled  with  well  preserved  blood.  A  further 
point  in  favor  of  the  Miiller's  duct  origin  is  that  these  adenomyomata 
resemble  in  every  particular  the  diffuse  adenomyomata  of  the  uterus, 
in  which  the  "lands  are  seen  to  be  direct  derivatives  of  the  uterine 
mucosa.  As  was  said  when  discussing  the  origin  of  adenomyomata 
of  the  uterus,  there  is  no  other  place  in  the  body  in  which  mucosa 
similar  to  normal  uterine  mucosa  is  found,  and  furthermore  no  other 
mucous  membrane  that  periodically  discharges  blood.  These  round 
ligament  adenomyomata  fulfil  every  requirement  of  normal  uterine 
mucosa.  It  would  be  unwise  to  say  absolutely  that  these  growths 
cannot  possibly  be  derived  from  remains  of  the  Wolffian  duct,  but 
the  evidence  is  overwhelmingly  in  favor  of  the  Miiller's  duct  origin. 
Before  concluding  a  consideration  of  these  cases  we  must  briefly 
refer  to  the  case  reported  by  Martin1  in  1891.  A  patient  aged 
seventy  consulted  him  about  a  rapidly  growing  tumor.  He  opened 
the  abdomen  and  removed  1 12  litres  of  chocolate-colored  fluid  from  a 
tumor  springing  from  the  left  round  ligament.  This  was  attached 
to  the  ligament  by  a  definite  pedicle.  Pommorsky,  who  made  the 
microscopic  examination,  found  that  the  cyst  containing  the  choco- 

1  Martin   A.:    Xur  Pathologie  des  Ligamentum  rotundum.      Ztschr.  f.  Geb.  u. 
Gvn.,  Bd.  xxii,  S.  1 1  \. 


254  ADEXOMYOMA  OF  THE  UTERUS 

late-colored  fluid  had  very  thin  walls,  and  that  its  inner  surface  was 
in  places  covered  by  clots.  The  pedicle  of  the  tumor  contained 
several  small  cysts  which  were  filled  with  clear  fluid  and  which  com- 
municated with  one  another.  One  of  these  cysts  was  lined  with 
low  cylindrical  ciliated  epithelium.  It  is  quite  probable  that  this 
was  an  adenomyoma  of  the  round  ligament  situated  nearer  the 
uterine  horn  than  usual.  I  noted  in  speaking  of  adenomyoma  of 
the  uterus  that  when  the  tumor  became  intraligamentary,  as  in  the 
case  represented  in  Fig.  43  (p.  151) ,  or  in  those  of  Breus  and  Kroenig, 
large  cysts  developed.  These  were  filled  with  chocolate-colored 
fluid  and  at  some  points  small  cysts  were  still  visible.  In  adeno- 
myoma of  the  round  ligament  situated  in  the  inguinal  region  or  in 
the  labium  ma  jus,  we  have  a  continual  surrounding  pressure,  as  in 
the  uterus.  In  Martin's  case,  on  the  other  hand,  there  was  nothing 
to  prevent  cystic  formation.  The  process  appears  to  be  analogous 
to  the  cystic  development  occurring  in  subperitoneal  or  intraliga- 
mentary adenomyomata  of  the  uterus. 

ADENOMYOMATA  OCCURRING  IN  BOTH  THE  RIGHT  AND  LEFT  ROUND 
LIGAMENT  IN  THE  SAME  INDIVIDUAL  (Figs.  67  and  68) 

Gyn.  No.  3891. 
L.  N.,  aged  thirty-seven.  Admitted  October  18,  1895.  The 
patient  has  been  married  thirteen  years  and  had  one  instrumental 
labor  seven  years  ago.  Her  menses  commenced  at  fourteen  and 
were  regular  until  the  birth  of  the  child,  since  which  time  they  have 
occurred  every  three  weeks,  have  been  very  copious,  and  have  lasted 
from  four  to  five  days.  The  latter  part  of  each  period  has  been  ac- 
companied by  a  good  deal  of  pain,  which  persists  for  several  days 
after  the  flow.  The  last  menstrual  period  occurred  two  weeks  be- 
fore admission.  About  eight  years  ago  the  patient  noticed  a  slight 
swelling  in  the  right  inguinal  region.  This  has  gradually  enlarged, 
more  especially  during  the  last  two  years.  She  has  had  severe  cut- 
ting pain  in  the  nodule  and  radiating  to  the  back.  This  has  been 
most  severe  after  exertion  or  during  the  menstrual  period.  The 
patient  is  much  debilitated.     The  vaginal  examination  is  negative. 


^DENOMYOMATA    OF    THE    ROUND    LIGAMENT  255 

The  mass  occupies  the  upper  part  of  the  righl  labium,  is  irregularly 
ovoid  and  firmly  fixed  in  I  he  deeper  tissues.     It  is,  however,  movable 

lo  the  extent   of  one  cent  iniet  re. 

October  L9th:  An  oval  incision  was  made  over  the  site  of  the 
nodule.  The  mass  was  freed  laterally  and  posteriorly.  Above  il 
was  closely  connected  with  a  hand  of  tissue,  1  cm.  broad.  This 
proved  to  be  the  righl  round  Ligament.  The  round  ligament  was 
traced  upward  to  the  internal  ring,  and  midway  bel  ween  the  external 
and  internal  ring  it  contained  a  nodule,  1  by  .6  cm.  The  round  liga- 
ment was  pulled  down,  clamped,  and  cut  off  at  the  internal  ring. 
Several  enlarged  lymph-glands  were  then  dissected  out.  The  pillars 
of  the  ring  wen1  brought  together  with  silver  wire  and  the  round  liga- 
ment was  sutured  into  the  canal.  The  patient  was  discharged  on 
November  3,  1895. 

Gyn.-Path.  No.  926. 

The  specimen  consists  of  a  piece  of  tissue  measuring  7  by  4  by 
3.5  cm.  One  surface  of  this  is  covered  with  normal  skin.  The  un<  ler- 
lying  tissue  is  composed  of  fat,  embedded  in  which  is  an  exceedingly 
firm  nodule,  measuring  3.5  by  3  by  2  cm.  (Fig.  67).  This  nodule  on 
section  is  composed  of  interlacing  bundles  of  fibres  which  form  a 
dense  network.  Scattered  throughout  the  nodule  are  many  small. 
irregular,  pale,  translucent,  homogeneous  areas.  On  examining 
the  specimen  after  hardening  in  Midler's  fluid  some  of  the  homo- 
geneous areas  are  found  to  contain  round,  oval,  or  irregular  space-. 

Histological  E  x  a  m  i  n  a  t  i  o  n  . — The  nodule  is  to  a 
great  extent  composed  of  non-striped  muscle  fibres  which  wind  in 
and  out  in  all  directions,  but  do  not  show  any  concentric  arrange- 
ment. In  many  places  the  muscle  fibres  arc1  swollen  and  the  cell 
protoplasm  contains  large  quantities  of  yellowish-brown  granular 
pigment.  At  several  points  the  muscle  has  undergone  hyaline  de- 
generation.    This    is    especially    noticeable    around    blood-vessels. 

The  blood-supply  is  abundant .  Scat  tered  here  and  t  here  1  hroughoul 
the  muscle  substance  are  small  islands  of  adipose  tissue.  Travers- 
ing the  nodule  in  all  directions  arc4  glands  (Fig.  68).     Some  of  these 


256  ADEX0MY0MA  OF  THE  UTERUS 

are  small  and  round  on  cross-section;  the  others  are  cut  lengthwise. 
These  glands  are  surrounded  by  stroma  similar  to  that  of  the  uterine 
mucosa.  It  would  be  impossible  to  distinguish  some  of  these  from 
uterine  glands.  A  few  of  the  glands  present  slight  dichotomous 
branching.  Some  of  them  contain  round  masses  of  protoplasm, 
scattered  throughout  which  are  several  nuclei.  These  giant  cells 
appear  to  be  cross-sections  of  tufts  of  epithelium.  In  many  places 
the  glands  present  a  peculiar  arrangement  and  correspond  to  von 
Recklinghausen's  pseudo-glomeruli,  which  consist  of  stroma  re- 
sembling  that   of   the   uterine   mucosa.     They    contain   numerous 


Fig.  67. — Adenomyoma  of  the  round  ligament.     (Natural  size.) 

Gyn.-Path.  No.  9  2  8.  The  figure  represents  a  longitudinal  section  of  the  tissue 
removed.  The  greater  part  consists  of  fat  and  the  surface  is  covered  with  skin.  Occupying 
the  lower  part  is  an  oval  area,  dark  in  color  and  composed  of  fibres  running  in  all  directions — 
the  myoma.  Passing  off  from  it  are  numerous  strands  which  merge  into  the  adipose  tissue. 
The  small  dark  areas  in  the  myoma  represent  dilated  gland  cavities.  The  large  and  small 
dark  masses  in  the  adipose  tissue  are  hemorrhages.  For  the  histological  picture  of  the  adeno- 
myoma see  Fig.  68. 

capillaries  and  may  have  one  or  more  glands  situated  in  their  depth. 
In  some  places  there  has  been  hemorrhage  into  their  stroma.  The 
pseudo-glomeruli  are  half-moon-shaped,  cone-shaped,  or  irregular 
in  contour.  They  are  covered  with  one  layer  of  cylindrical  ciliated 
epithelium.  What  corresponds  to  Bowman's  capsule  consists  of  a 
layer  of  cells  resting  directly  upon  the  muscle  fibres.  The  cells  of 
the  capsule  opposite  the  convexity  of  the  glomerulus  are  almost 
flat.  On  passing  off  laterally  they  are  seen  to  be  cuboidal  or  cylin- 
drical. The  cells  of  the  so-called  capsule  are  directly  continuous 
with  those  of  the  pseudo-glomerulus.     The  space  between  the  cap- 


A.DENOMYOMATA    OF    THE    ROUND    LIGAMENT 


257 


sule  and  the  glomerulus  may  be  empty.  Many,  however,  contain 
desquamated  epithelial  cells,  some  of  which  are  vacuolated  and  have 
brown,  granular  pigment  in  their  interior.  Numerous  spaces  con- 
tain  blood-COrpuscles.      On   tracing  one  of  the  spaces  laterally   it    is 

found  to  be  directly  continuous  with  the  lumen  of  a  gland.  The 
capsule  forms  one  wall  of  the  gland  and  the  pseudo-glomerulus  the 

other  (Fiii'.  OS).  In  other  words,  the  space  between  the  capsule  and 
the  so-called  glomerulus  is  nothing  more  than  a  dilatation  of  the 


. 


«r 


Fig.  68.— Adenomyoma  of  the  Round  Ligament.     (20  diameters.) 

Gyn.-Path.  No.  9  28.  The  section  is  taken  from  the  oval  nodule  in  Fig.  t>7. 
The  framework  consists  of  non-striped  muscle  fibres  cut  chiefly  longitudinally.  Scattered 
throughout  the  muscle  are  glands  which  occur  singly  or  in  groups.  They  arc  round,  oval  or 
irregular  and  show  some  branching.  All  are  lined  with  one  layer  of  cylindrical  epithelium  and 
even  the  smaller  ones  are  surrounded  by  a  definite  stroma  which  with  the  high  power  is  seen 
to  be  identical  with  that  of  the  uterine  mucosa.  In  the  right  lower  corner  is  adipose  tissue. 
A  few  stray  fat  cells  arc  found  in  the  myoma.  In  the  left  upper  corner  is  a  so-called  pseudo- 
elomerulus. 


inland  cavity  or  of  a  miniature  uterine  cavity.  In  numerous  places 
the  gland  epithelium  on  one  side  is  found  to  he  cylindrical;  on  the 
other  side,  cuboidal  or  almost  Hat.  On  examining  these  more  closely 
it  is  found  that  where  the  epithelium  is  separated  from  the  muscle 
by  a  moderate  amount  of  stroma  it  is  cylindrical,  hut  where  the 
epithelium  rests  directly  upon  the  muscle,  it  is  invariably  cuboidal 
or  flat.  A  few  small  glands  are  seen  Lying  directly  between  muscle 
bundles. 

17 


258  ADENOMYOMA  OF  THE  UTERUS 

Extending  into  the  myomatous  growth  from  the  periphery  are 
numerous  bands  of  connective  tissue.  The  adipose  tissue  surround- 
ing the  myoma  shows  considerable  hemorrhage.  The  skin  cover- 
ing the  surface  of  the  specimen  is  normal.  Unfortunately  we  were 
not  able  to  obtain  the  smaller  nodule  of  the  round  ligament  for  ex- 
amination and  cannot  say  whether  it  was  an  adenomyoma  or  not. 

The  patient  was  readmitted  on  May  25,  1897.  Shortly  after 
the  previous  operation  she  noticed  a  swelling  in  the  opposite  (left)  in- 
guinal region  immediately  above  the  pubes.  This  has  gradually 
increased  in  size  and  is  quite  painful.  The  menstrual  period  has 
not  been  regular,  occurring  at  intervals  of  from  three  to  five  weeks. 
The  last  menstruation  commenced  May  18th  and  ceased  May  23d. 
On  May  26th  I  removed  the  nodule  with  little  difficulty  and  found 
that  it  was  directly  continuous  with  the  left  round  ligament. 

Gyn.-Path.  No.  1741  . — The  specimen  consists  of  an 
irregular  mass,  approximately  3  cm.  in  its  various  diameters.  It 
comprises  a  firm  central  portion,  1.5  cm.  in  diameter,  and  is  sur- 
rounded on  all  sides  by  adipose  tissue.  Traversing  the  central  por- 
tion are  numerous  delicate  fibres  and  at  several  points  are  brown  or 
yellow  homogeneous  areas.  Several  pin-point  cavities  are  demon- 
strable. At  one  point  is  a  semicircular  slit,  2  mm.  long,  and  in  the 
immediate  vicinity  an  irregular  cavity  averaging  3  mm.  in  diameter. 
The  walls  of  this  cavity  are  rather  uneven  and  are  slightly  granular. 

Histological  Examination  . — The  adipose  tissue 
in  the  outlying  portions  is  comparatively  normal,  but  as  one  ap- 
proaches the  firm  nodule  the  blood-vessels  increase  in  number  and 
size.  Young  capillaries  are  found  wandering  in  between  the  fat  cells, 
the  fat  cells  becoming  gradually  separated  from  one  another.  At 
the  margin  of  the  firm  nodule  the  growth  is  composed  almost  ex- 
clusively of  connective  tissue.  Here  and  there  this  connective 
tissue  encircles  round  or  oval  clumps  of  cells  having  oval,  some- 
what deeply  staining  nuclei.  Scattered  between  these  are  a  few 
small  round  cells  and  occasionally  polymorphonuclear  leucocytes. 
Such  areas  are  very  striking  on  account  of  their  richness  in  nuclei, 


\l>i;\o\n  o\l  \T.\    OF   THE    ROl   ND    LIGAMENT  259 

in  contrasi  to  the  surrounding  tissue,  which  is  poor  in  cell  elements. 
The  cellular  areas  resemble  closely  the  stroma  of  the  uterine  mucosa. 
<)n  passing  toward  the  centre  of  the  nodule  similar  areas  are  found 
containing  one  or  more  glands  lying  in  their  centre  or  al  the  peri- 
phery. These  glands,  according  to  the  angle  al  which  they  have 
been  cut,  are  round,  elongate,  or  slightly  branching.  Their  epithe- 
lium is  cylindrical,  apparently  ciliated,  and  their  nuclei  are  oval  and 
situated  at  some  distance  from  the  bases  of  the  cells.  Iii  short ,  these 
glands  cannot  he  distinguished  from  uterine  glands.  The  majority 
of  the  gland  cavities  are  completely  filled  with  blood  and  desquamated 
epithelial  cells.  The  stroma  of  the  central  portion  of  the  nodule  is 
composed  almost  entirely  of  non-striped  muscle  fibres,  and  here 
the  glands  are  abundant  and  present  a  more  complicated  picture. 
They  are  branching,  form  narrow*  channels  and  little  bays,  and 
in  places  can  he  traced  in  their  continuity  for  at  least  4  mm.  On 
one  side  of  the  gland  there  is  usually  a  considerable  amount  of  stroma 
separating  the  epithelium  from  the  underlying  muscle.  At  such 
points  the  epithelium  is  cylindrical,  but  on  the  opposite  side,  where 
the  cells  rest  directly  on  the  muscle,  it  is  frequently  flattened.  There 
are  a  few  areas  corresponding  to  von  Recklinghausen's  pseudo- 
glomeruli.     Some  of  these  contain  glands,  others  do  not. 

The  nodules  in  both  round  ligaments  are  typical  adenomyomata. 


SUMMARY 

In  cases  of  adenomyoma  of  the  uterus  we  usually  find  a  diffuse 
myomatous  thickening  of  the  uterine  muscle.  This  thickening  may 
be  confined  to  the  inner  layers  of  the  anterior,  posterior,  or  lateral 
walls,  but  in  other  cases  the  myomatous  tissue  completely  encircles 
the  uterine  cavity. 

This  diffuse  myomatous  tissue  contains  large  or  small  chinks,  and 
into  these  chinks  the  normal  uterine  mucosa  flows.  If  the  chinks 
are  small,  there  is  only  room  for  isolated  glands,  but  where  the 
spaces  are  of  goodly  size  large  masses  of  mucosa  flow  into  and  fill 
them.  We  accordingly  have  a  diffuse  myomatous  growth  with 
normal  mucosa  flowing  in  all  directions  through  it.  The  mucosa 
lining  the  uterine  cavity  is  perfectly  normal. 

After  a  time  portions  of  the  diffuse  myoma  may  be  nipped  off 
and  are  carried  toward  either  the  outer  or  inner  surfaces  of  the  uterus. 
If  they  become  submucous  growths,  they  are  gradually  expelled. 
If  they  pass  toward  the  outer  surface,  they  become  either  subperi- 
toneal or  intraligamentary.  We  have  accordingly  divided  adeno- 
myomata  into  the  following  groups: 

1.  Adenomyomata  in  which  the  uterus  preserves  a  relatively 
normal  contour. 

2.  Subperitoneal  or  intraligamentary  adenomyomata. 

3.  Submucous  adenomyomata. 

A  diffuse  adenomyoma  presents  a  very  coarse  appearance,  owing 
to  the  fact  that  the  myomatous  muscle  bundles  run  in  all  directions. 
In  the  spaces  between  bundles  and  occasionally  surrounded  by  cir- 
cular rings  of  muscle  we  find  spaces  filled  with  translucent  and  slightly 
punctiform  tissue — areas  of  uterine  mucosa.  Sometimes  its  direct 
connection  with  the  mucosa  of  the  uterine  cavity  can  be  traced. 
Often  are  noted  cyst-like  spaces  scattered  throughout  the  diffuse 
myoma.     These  are  filled  with  a  chocolate-colored  fluid  and  are  lined 


260 


SI  MMARY  li<  *»  1 

with  a  definite  membrane,  often  1  i<>  2  mm.  thick.  They  are  mini- 
ature uterine  cavities  and  the  chocolate-colored  fluid  is  old  men- 
strual Mood  thai   could  not  escape. 

When  an  adenomyomatous  nodule  becomes  subperitoneal,  the 
menstrua]  flow  in  the  growth  may  gain  the  upper  hand  and  the 
myoma  become  cystic,  the  contents,  of  course.  being  formed  from 
the  accumulation  of  old  menstrual  blood. 

Sympt  onis.*  -Our  youngest  patient  was  nineteen,  our 
oldest  sixty.  The  disease  is  most  prevalent  Let  ween  the  thirtieth 
and  sixtieth  years;   it  does  not  in  any  way  tend  to  sterility. 

Lengthened  menstrual  periods  are  the  first  symptom.  The 
flow  gradually  assumes  the  proportions  of  hemorrhages  and  event- 
ually the  period  may  become  continuous. 

At  the  period  there  is  often  discomfort,  and  occasionally  a  grind- 
ing pain  in  the  uterus,  evidently  due  to  the  increased  tension,  since 
all  the  islands  of  mucosa  scattered  throughout  the  diffuse  myoma 
naturally  swell  up  at  the  menstrual  period,  and  thus  increase  the 
size  of  the  organ. 

In  over  two-thirds  of  our  cases  there  was  no  intermenstrual  dis- 
charge. This  is  perfectly  natural,  as  in  these  cases  the  uterine 
mucosa  is  normal  and  no  disintegration  of  tissue  is  going  on. 

Clinically  the  diagnosis  of  diffuse  adenomyoma  is  rela- 
tively  easy,  for  the  following  reasons: 

1.  The  bleeding  is  usually  confined  to  the  period. 

2.  There  is  usually  much  pain,  referred  to  the  uterus,  at  the 
period. 

*  While  von  Recklinghausen  was  carrying  mi  his  work  on  the  pathology  of 
adenomyoma  W.  A.  Freund  was  carefully  analyzing  the  symptomatology  in  such 
cases  to  determine,  it  possible,  whether  the  clinical  picture  was  sufficiently  charac- 
teristic to  enable  the  surgeon  i<>  make  a  diagnosis  before  operation.  In  contrast 
with  his  findings,  our  experience  p>es  to  show  that  neither  an  infantile  condition  of 
l  he  uterus  nor  sterility  is  in  any  sense  a  prominent  feature. 

Von  Etosthorn  (Med.  Klin.  Berlin,  L905,  1.  201  203),  in  a  recent  publication. 
reports  two  cases,  in  one  of  which  the  clinical  picture  before  operation  strongly  sug- 
gested diffuse  adenomyoma.  He  says  that  in  the  future,  with  our  increased  knowl- 
edge, a  provisional  diagnosis  of  adenomyoma  is  sometimes  possible  before  operation. 


262  ADENOMYOMA  OF  THE  UTERUS 

3.  There  is  usually  no  intermenstrual  discharge  of  any  kind. 

4.  The  uterine  mucosa  is  perfectly  normal  and  may  be  rather 
thick. 

No  other  pathological  condition  of  the  uterus,  as  a  rule,  gives  this 
characteristic  picture. 

Treatment  . — The  patient's  health  is  often  gradually  under- 
mined by  the  uterine  hemorrhages,  and  the  only  way  to  control  them 
is  to  remove  the  uterus.  A  supravaginal  hysterectomy  is  all  that  is 
necessary.     The  ovaries  should  be  saved. 

The  prognosis  is  good,  as  the  glands  of  the  adeno- 
myoma  are  perfectly  normal  uterine  glands  and  are  surrounded  by 
the  characteristic  stroma  of  the  mucosa. 

Origin  . — The  glands  in  the  adenomyoma  originate,  in  the 
vast  majority  of  the  cases  at  least,  from  the  uterine  mucosa.  The 
reader  will  be  thoroughly  convinced  of  this  after  studying  the  vari- 
ous histological  pictures  in  the  book. 

Cause  . — The   cause  of  adenomyoma  is  still  unsolved. 


INDEX  OF  CASES  ARRANGED  ACCORDING  TO  THEIR 
GYNECOLOGICAL  NUMBERS 


HNS  Hopkins  Hommt  ai 


<  lyn.  No. 

<  }yn.  Nn. 

<  lyn.  No. 
Gyn.  No. 
(  lyn.  NO. 
( i\  n.  No. 
Gyn.  No. 

(  Ivn.  No. 
Gyn.  No. 

( lyn.  No. 
( ivn.  No. 
( ivn.  No. 
( Ivn.  No. 
( Ivn.  Nil 
( lyn.  No. 


Gyn. 

(lyn 

( ;>-n 

( ivn 

(lyn 
( lyn 
( lyn 


No. 

No. 
No. 

No. 
N... 
No. 

No. 


(  lyn.  Nn. 
(  Ivn.  No. 
(Ivn.  No. 
•  lyn.  No. 
( Ivn.  No. 
Gyn.  No. 
Gyn.  No. 
(  lyn.  No. 
<  lyn.  No. 
(Ivn.  No. 
Gyn.  No. 


(lyn 
( ivn 
(Ivn 
<  lyn 
(Ivn 
Gyn 


No. 

No. 
No. 
No. 
No. 
No. 


( lyn.  No. 
( lyn.  Nn. 
( lyn.  No. 
( lyn.  No. 
( lyn.  No. 
i lyn.  No. 
( lyn.  No. 
( lyn.  No. 


i'.-.::; 
2699 
2706 
27  1 I 
•-'To  I 
2806 
3126 
3136 
3192 
3204 
3293 
3379 
3395  . 
3399  . 
3401  . 
3418  . 
3600  . 
3614  . 
3715  . 
3805  . 
3809  . 
3891  . 
:;sos 

1364  . 

til.".  . 
5768 
5782  . 
5973  . 
cits:;  . 
6240  . 
6635 

lis.-,.-, 
lis.-,.-, 
7D11    . 
7153  . 
7569  . 
7 s.V.i  . 
8438  , 
si  117  . 
8780 
9024 
9069  . 
9457  . 
9637 
9788 
9971. 
1031  1 


17 
93 
29 
r,l 
12 
17 
213 
7o 
52 
50 

r.i-2 

2  17) 
240 
244 
241 

8 

INS 

23 
240 

240 
31 

27.4 
Uiii 

'.17 
190 

:,  I 
218 
158 

68 

200 

239 

160 

149 

108 

34 

ss 

109 

223 

128 

1  19 

L38 

33 

60 

139 

85 

209 

101 


PAGE 

Gyn.  No.  L0516 203 

(Ivn.  No.  L0519.  86 

(Ivn.  No.  los72 L63 

Gyn.  No.  11120 100 

Cvn.  No.  112.V2 Ill 

(ivn.  N...  L1363 loo 

Gyn.  No.  11572 238 

(Ivn.  No.  lls.-,i) 10 

(Ivn.  N...  12036 145 

(Ivn.  No.  12000 212 

(Ivn.  No.  L2080 »7, 

(Ivn.  No.  12221 

(Ivn.  N...  12304 21:; 

Gyn.  N...  L2358 117 

Cvn.  N...  12:;so _M0 

(Ivn.  No.  L2585 no 

Gyn.  No.  L2599 22 

Cvn.  No.  1207s lot 

Cvn.  N...  12681 11 

Cvn.  No.  12807 82 

Gyn.  No.  12841 83 

Cvn.  N...  12918 206 

Gyn.  No.  1204  1 95 


San. 
San. 

San. 
San. 

San. 
San. 
San. 
San. 
San. 
San. 
San. 


No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 
No. 


Hi'.  I 
1453 
1 552 
ls(7 
1 852 
1872 
1913 
1931 
L944 
21  II 
217- 


■  Howard  A.  Kelly 


62 
115 
105 

-_' 

110 
122 

20 
123 

in 
103 


( 'Imrcli  Home  and  Infirmary. 

Case  No.               G.  L.  Hunner) 99 

\.i.    51 1       Thomas  Cullen  1 21 1 

Case  No.  1019      Thomas  Cullen  113 

Case  No.  1517      Thomas  Cullen) 212 

Dr.  W.  W.  Russell's  patient 67 

Emergency      Hospital,      Frederick,     Md. 

Thomas  Cullen) 119 

1  >r.  Joseph  Price's  case  228 


263 


INDEX  OF  GYNECOLOGICAL-PATHOLOGICAL 

NUMBERS 


Gyn, 

( iyn.- 
( ivn.- 
Gyn.- 
<  ;>...- 
Gyn.- 

(ivn, 

Gyn, 
Gyn, 
Gyn, 
Gyn.- 
Gyn.- 
Gyn, 
Gyn.- 
Gyn.- 
Cyn, 
Gyn, 
Gyn, 
<;>-.., 

(Ivil, 

Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn.- 
Gyn, 
( ivn.- 
Gyn, 
Gyn, 
( ivn.- 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
(Ivn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn. 
Gyn. 
Gyn. 


Pal 
Pal 
Pal 
Pa1 
Pal 
Pat 
Pal 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pat 
Pal 
Pat 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pat 
Pat 
Pat 
Pat 
Pa1 
Pat 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pal 
Pat 
Pal 
Pal 
Pal 
Pal 
Pat 
Pat 


i.  No. 
i.  Nn. 
i.  No. 
i.  No. 
i.  No. 
i.  Nil 
,.  No. 
i.  Xd. 
..  X.i. 
1.  X... 
..  X... 
i.  X... 
..  No. 
,.  No. 
i.  No. 
i.  No. 
i.  No. 
i.  No. 
i.  No. 
..  No. 
i.  No. 
i.  Xd. 
i.  No. 
l.  No. 
l.  X... 
l.  No. 
i.  No. 
i.  X.i. 
i.  No. 
..  No. 
No. 
i.  Xn. 
..  No. 
i.  X... 
..  No. 
..  X... 
i.  X... 
i.  No. 
i.  X... 

l.  Xn. 

i.  Xn. 
i.  No. 
i.  No. 

i.  Xn. 
..  X... 
i.  Xd. 
..  Xd. 

i.  Xd. 


163. 
245. 
246. 

•_'7  1 . 
290. 


193. 

197. 

:.■_>;». 

526. 

583 . 

633. 

hi;.. 

647. 

649. 

659. 

661. 

i  77. 

7NN. 

843. 

ss|  . 

892. 

928. 

934. 
1170. 
l'_'(>7. 
1711. 
L758. 
2066. 

JOIN. 

2075. 
2084. 

•'•'"id 


2356. 
2532. 
2845. 

:;ui7. 
3289. 
3429. 


3721. 
3903. 
U22. 
1656. 
1820. 
|s:;s. 

1966. 

:.is:. 


17 
29 

93 
61 
!'_' 
17 
213 
7.") 
52 
;,() 

1  :•!•_> 
245 
244 
241 
240 
17s 

8 
iss 

JA 
240 

:-tl 
240 
2.-..-. 
166 

97 
190 
258 

62 

.".1 
179 

2  IS 
2is 
1 58 

68 
21 1( ) 
239 
160 
108 

34 
238 

ss 

L09 
223 

237 

l_'s 
I  I'.i 
IMS 


Gyn.- 
Gyn.- 
Gyn, 

<;>•„, 
Gyn, 

( iyn.- 
( Ivn.- 
Gyn, 

<  ,VII, 

( iyn.- 
Gyn, 
Gyn, 
Gyn, 

(  iyn.- 

<  ryn, 

( Ivn.- 

Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 

<lyu, 

Gyn, 
(ivn, 
(Ivn, 
(Jvn, 
(iVn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
Gyn, 
( lyn, 

( Ivn.- 

Gyn, 
Gyn, 
( ryn, 
Gyn, 
Gyn, 
( Ivn. 
Gyn, 
Gyn, 


Pal 
Pat 
Pat 
Pat 
Pal 
Pal 
Pat 
Pat 
Pal 
Pat 
Pat 
Pal 
Pat 
Pal 
Pal 
Pal 
Pal 
Pal 
Pat 
Pa1 
Pal 
Pat 
Pat 
Pat 
Pat 
Pat 
Pat 
Pa1 
Pat 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 
Pat 
Pa1 
Pat 
Pal 
Pat 
Pat 
Pat 
Pat 


PACI 

i.  Xn.  .".tills 

i.  X...  5840 139 

i.  No.  6008 x-"i 

i.  Xd.  6150 209 

i.  Xn.  6216 115 

i.  X<».  6319 99 

i.  X.i.  6531 161 

i.  X...  6536 L05 

i.  Xn.  6754 86 

i.  No.  6764 - 

i.  Xn.  7026 1M 

«.  Xd.  7076 163 

i.  Xd.  7351 100 

i.  No.  7507 Ill 

i.  Xi».  7593 106 

l.  Xn.  7800 2:;s 

i.  No.  8197 L6 

i.  X«».  8346 230 

i.  X...  8347 225 

i.  No.  8393 119 

i.  X...  sun 211 

..  X<».  8433 14i» 

i.  Xd.  8579 145 

i.  Xd.  8602 212 

i.  No.  8641 122 

i.  No.  8715 15 

i.  No.  8760 10 

i.  Xd.  8807 123 

i.  Xd.  ss:;j 2   - 

i.  Xd.  ssim) 213 

i.  No.  8983 117 

i.  Xd.  9281 246 

i.  Xd.  9312 228 

i.  X...  9336 11" 

).  X...  9366 22 

i.  Xn.  9367 20 

i.  X...  9107 113 

i.  No.  9466 l") 

l.  No.  97)17 It 

1.  Xd.  9099 sj 

i.  No.  970.") 1" 

i.  No.  9711 

i.  X...  9803 103 

i.  No.  os  ii 206 

i.  No.  9858 

i.  Xd.  0970 95 

l.  No.  10771 170 

i.  No.  10669 212 


INDEX 


Abortion    and   adenomyoma,   differentiation, 

183 
Abscess,  in  uterine  cornu,  2 1 ! 

miliary,  of  ovary,  2 10 

tubo-ovarian,  17 
Adenocarcinoma,  and  adenomyoma  occurring 
independently  in  same  uterus,  218 

developing  from  adenomyoma,  222 

cases  of,  223 

Adenocystoma  of  ovary,  97 
Adenomyoma,  I 

adenocarcinoma  developing  from,  222 
cases  of,  223 

and  abort  ion,  differenl  tal  ion,  I  83 

and  adenocarcinoma  occurring  independenl  ly 
in  same  uterus.  _' 1 8 

and  carcinoma,  differentiation,  I7.">,  185 

and  chorioepithelioma,  differentiation,  L83 

and  endometritis,  differentiation,  184 

and  large  and  dilated  uterine  glands  with 
overgrowth  of  struma  of  mucosa,  differen- 
tiation, L80 

and  myoma,  differentiation,  182 

and  polypi,  differentiation,  1  78 

and  proliferation  of  stroma  of  uterine  mucosa 
associated  with  copious  uterine  hemor- 
rhages, differentiation,  1  80 

and  salpingitis,  differentiation,  184 

and  sarcoma,  differentiation,  183 

and  tubal  pregnancy,  differentiation,  184 

and  venous  sinuses  in  uterine  mucosa,  differ- 
enl iat ion.  1  79 

arising  from  uterine  portion  of  uterine  horn, 
235 

benign  character  of,  cases  illustrating,  188 

cases  of  diffuse,  8 

causes  of,  199,  262 

cervical.  !(>."> 

clinical  picture  in.  1 73 

commencing,  20,  29,  31,  '■>'■>.  50,  52,  <>7.  83 

condition  of  tubes  and  ovaries  in,  171 

diagnosis  of,  175,  261 
differential,  177 

diffuse,  cases  of,  8 
and  squamous-cell  cancer  of  cervix,  206 
hypertrophy  of  cervix  and.  _'on 


V.den<  myoma, diffuse, of  uterine  horn, 235, 246 

origin  of,  193 

prognosis  in,  187,  262 

symptoms  of ,  ]  73,  261 

treatment  of,  186,  261 
discharge  in,  1  7:; 
discrete,  60,  I  10 

in  left  uterine  horn.  100 

of  utero-ovarian  ligament  .ill 
from  tubal  portion  of  uterine  horn,  236 
hemorrhage  in,  17:; 
incidence  of,  17  1 

in  one  horn  of  bicornate  uterus,  203 
in  right   and  left    round  ligament    in    same 

person.  25  1 

interst itial,  P''s 
intraligamentary,  1  15 
case  of,  149 
cystic,  1  18 
of  round  ligament .  250 

origin  of,  '-'.YJ 
of  uterine  horn,  29,  52,  67,   LOO,   1 17.  119, 
235,  237,  239,  240,  241,242,  244,  245, 
246 
decidua  developing  in  adenomyoma  of, 
246 
origin  of,  1  93 
pain  in,  1  73 

physical  examinat  ion  in,  1  75 
prognosis  in,  187 
relat  ion  of,  to  pregnancy,  1  7  1 
submucous,  156 

cases  of,  1  19,  158,  L60,  161,  163 
origin  of,  !'.»•"> 
subperitoneal,  l'_\"> 
cases  of,  114,128 
cystic,  128 
origin  of,  19  1 
summary  of,  260 

treatment   of,   186 

uterus  preserving  relatively  normal  contour.  2 

cases  of,  s 
cystic  glands  in,  6 
cyst-like  spaces  in,  :> 
dilated  glands  ill.  6 
elands  in,  I.  5,  7 


26; 


268 


INDEX 


Adenomyoma,  uterus  preserving  relatively  nor- 
mal   contour,   histological   ap- 
pearances, 5 
islands  of  glandular  tissue  in,  6 
thickening  in,  2,  3 
uterine  mucosa  in,  5 
vaginal  discharge  in,  173 
Adhesions,  pelvic,  31,  46,  50,  67,  82,  84,  97,  103, 

109, 138,  149,  245 
Age  at  which  adenomyoma  occurs,  174 
Atrophy  of  uterine  mucosa,  133,  240,  241,  244 


Bicornate  uterus,  adenomyoma  in  one  horn 
of,  203 


Canal,  von  Recklinghausen's,  7 
Carcinoma   and    adenomyoma,  differentiation, 
175, 185 
squamous-cell,  of  cervix,  diffuse   adenomy- 
oma of  corpus,  206 
Cervical  adenomyoma,  165 
Cervix,  double,  161 

hypertrophy  of,  and   diffuse    adenomyoma, 

200 
squamous-cell    cancer   of,  diffuse  adenomy- 
oma of  corpus,  206 
Chorioapithelioma    and    adenomyoma,    differ- 
entiation, 183 
Cyst,  Graafian  follicle,  82 

of  ovary,  34,  50,  60,  82,  93,  97,  166,  238,  245 
tubo-ovarian,  29 
Cystadenoma  of  ovary,  97,  238 

with  carcinomatous  changes,  238 
Cystic  adenomyoma,  subperitoneal,  128,  132 
glands  in  adenomyoma  in  which  uterus  pre- 
serves relatively  normal  contour,  6 
intraligamentary  adenomyoma,  148 
spaces  in  uterine  horn,  119,  243 
Cyst-like    spaces    in    adenomyoma    in    which 
uterus  preserves  relatively  normal  contour,  5 
Cysts,  multiple,  in  subperitoneal  myoma,  128, 
132 


Decidua  developing  in  stroma  of  adenomyoma 

of  uterine  horn,  246 
Diagnosis,  175 
differential,  177 
from  abortion,  183 
from  cancer,  185 
from  chorio-epithelioma,  183 
from  endometritis,  184 
from  large  venous  sinuses  in  the  mucosa, 
179 


Diagnosis,  differential,  from  marked  prolifera- 
tion of  the  stroma  of  the  mucosa,  180 
from  myomata,  182 
from  polypi,  178 

from  salpingitis  and  endometritis,  184 
from  sarcoma.  183 
from  tubal  pregnancy,  184 
from  very  large  and  dilated  uterine  glands 
with  overgrowth  of  stroma  of  mucosa, 
180 
Dilated  glands  in  adenomyoma  in  which  uterus 

preserves  relatively  normal  contour,  6 
Discharge  in  adenomyoma,  173 
Double  cervix,  161 
vagina,  161 


Edema  of  uterine  mucosa,  50,  128,  133 
Endometritis,  and  adenomyoma,  differentiation, 
184 

chronic,  45 

slight,  22,  41,  117 

subacute,  64 
Endometrium,  gland  hypertrophy  of,  140,  149, 

246.     (See  Mucosa.) 


Fallopian  tube,  left,  pregnancy  in,  246 
accessory  ostium  of,  241 
tubes,  condition  of,  in  adenomyoma,  171 


Gland  hypertrophy  of  endometrium,  140,  149, 

246 
Gland-like  spaces   in  uterine   horn,  240,  241, 

244,  245 
Glands,  cystic,  in  adenomyoma  in  which  uterus 
preserves  relatively  normal  contour,  6 
dilated,    in   adenomyoma   in   which    uterus 

preserves  relatively  normal  contour,  6 
in  adenomyoma  in  which  uterus   preserves 

relatively  normal  contour,  4,  5,  7 
uterine,  large  and  dilated,  with  overgrowth 
of  stroma  of  mucosa,  adenomyoma  and,  dif- 
ferentiation, 180 
Glandular  tissue,  islands  of,  in  adenomyoma  in 
which  uterus  preserves  relatively  normal 
contour,  6 
uterine  polyp,  75,97,  178 
Graafian  follicle  cyst,  82 


Hauptkanal  of  von  Recklinghausen,  7 
Hematosalpinx,  109 

Hemorrhage,   into   and   thickening  of   uterine 
mucosa,  24 


I  \  I )  E  X 


Hemorrhage   from   venous  sinuses   in   uterine 
mucosa,  adenomyoma  and,  differentiation, 
IT'.* 
in  adenomyoma,  lT.'i 
Hydrosalpinx,  29,  166,  241 
Hypertrophy,  gland,  of  endometrium,  140<  149, 
246 
nt  cervix  ami  diffuse  adenomyoma,  200 


I.vtkusti  ii  \i.  adenomyoma .  138 
Intraligamentary  adenomyoma,  I  15 

case  of,  1  I'.t 

cysl  ic,  l  Is 


Ligament,  round,  adenomyoma  of,  250 
origin,  _'.v_' 
right  and  left,  adenomyoma  in,  in  same 

person.  '_'."> ( 
utero-ovarian,  discrete  adenomyoma  of,  141 


Miliary  abscesses  of  ovary.  240 
Miniature  uterine  cavities,  3,  69,  100,  141.  161 
Mucosa,  uterine.  ;i trophy  of,  133,  240,  241,  '_'  1 1 
edema  of,  50.  128,  133 
hemorrhage  into  and  thickening  of.  24 
hypertrophy  of,  140,  149,  246 
in  adenomyoma  in  which  uterus  preserves 

relatively  normal  contour.  <i 
polypi  of.  To.  07.  17s 
stroma    of.  proliferation,  associated   with 
copious  uterine  hemorrhage,  differentia- 
tion from  adenomyoma,  180 
venous  sinuses  in.  and  adenomyoma.  differ- 
entiation, 17'.» 
Multiple  cyst-  in  subperitoneal  myoma.  128, 132 

Myoma  and  adenomyoma,   differentiation.    1  82 

Myomatous  thickening,  diffuse,  but  no  glandular 
invasion  of  uterine  walls,  230 


<  Istium,  accessory,  oi  Fallopian  tube,  241 

Ovary,  adenocystoma  of.  97,238 
condition  of,  in  adenomyoma.  171 
cysl  of,  34,  50,  60,  82,  '■>■>.  97,  166,  238,  241 

witli  carcinomatous  changes,  238 
miliary  abscesses  of.  2 K) 
papillocystoma  of,  166 


P  \i\  in  adenomyoma,  173 
Papillocystoma  of  ovary,  1  *  • » » 
Pathological  changes,  multiple,  in  the  pelvis 
228 


Pelvic*  adhesions,  24,  31,  :;.;.  34,  16    17 
07,  82,  84,  97,  103,  108,   109,   138,  1  19,  166, 
171.  Jin.  245 

Pelvis,  pathological  changes  i: 

Physical  examination  in  adenomyoma,  17.'» 

Polyp,  ami  adenomyoma.  differentiation,  17^ 
glandular  uterine,  7.">.  07 

Pregnancy,  in  lefl  Fallopian  tube,  246 

relation  of  adenomyoma   to.    17  1 

tubal,  and  adenomyoma.  differentiation,  1M 
Proliferation  of  stroma  of  uterine  mucosa  asso- 
ciated   with    copious    uterine     hemorr 

adenomyoma  and.  differentiation,  180 
Purulenl  salpingitis,  acute.  10 


Eioi  \ii  ligament,  adenomyoma  of.  250,  252 

right    ami    left .  adenomyoma    in.    in    -aim- 

person,  254 


Salpingi  :  1-.  84,  171 
acute  purulent.   16 

and  adenomyoma.  differentiation,  1M 
chronic.  46,  240,  244 
Sarcoma  and  adenomyoma, differentiation,  183 
Sinuses,  venous,  in  uterine  mucosa,  and  adeno- 
myoma, differentiation,  179 
S.|iiainous-cell  cancer  of  cervix,  diffuse  adeno- 
myoma of  body,  -06 
Stroma  of  uterine  mucosa,  proliferation 
sociated   with  copious  uterine    hemorr      e 
adenomyoma  and.  differentiation,  l^n 
Submucous  adenomyoma.  149,   156,   158,   160, 
mi.  103 
cases  of.  1 58 
origin  of.  195 
Subperitoneal  adenomyoma.  114.  125,  138,  139, 
1  XI.  1  t:. 
cases  of,  128 
cystic,  128,  132 
origin  of.  p.i  1 
multiple  cysts  in.  128,  132 


Thickening,  and  hemorrhage  from  uterine  mu- 
cosa ,  2  l 

in   adenomyoma    in   which   uterus    pr<  - 
relatively  normal  contour.  _' 
diffuse  'if  uterine  wall,  but   no  glandular 
invasion.  1  t.  22,  0  1.  230 
Tubal    portion  of   uterine   horn,  adenomyoma 
from.  236 
pregnancy  and  adenomyoma,  differentiation. 
184 


270 


INDEX 


Tubes,  condition  of,  in  cases  of  adenomyoma, 

171 
Tubo-ovarian  abscess,  47 

cyst,  29 


Uterine  glands,  large  and  dilated,  with  over- 
growth of  uterine  mucosa,  adenomyoma 
and,  differentiation,  180 
horn,  abscess  in,  244 

adenomyoma  in,  29,  52,  67,  100,  117,  119, 
235,  237,  239,  240,  241,  242,  244,  245, 
246 
tubal  portion  of,  adenomyoma  from,  236 
uterine   portion   of,  adenomyoma   arising 
from,  235 
mucosa,  atrophy  of,  133,  240,  241,  244 
edema  of,  50,  128,  133 
hemorrhage  and  thickening  of,  24 
hypertrophy  of,  140,  149,  246 
in  adenomyoma  in  which  uterus  preserves 
relatively  normal  contour,  5 


Uterine  mucosa,  polypi  of,  75,  97,  178 

stroma    of,  proliferation,  associated   with 
copious  uterine  hemorrhages,  adenomy- 
oma and,  differentiation,  180 
venous  sinuses  in,  and  adenomyoma,  differ- 
entiation, 179 
polyp,  75,  97 
walls,  adenomyoma  of,  2, 

benign  character,  188,  190 
myomatous  thickening  of,  14,  22,  23,  64, 
230 
Utero-ovarian  ligament,  discrete  adenomyoma 

of,  141 
Uterus,  bicornate,  adenomyoma  jn  one  horn 
of,  203 


Vagina,  double,  161 
Vaginal  discharge  in  adenomyoma,  173 
Venous  sinuses  in  uterine  mucosa  and  aden- 
omyoma, differentiation,  179 
Von  Recklinghausen's  canal,  7 


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